MEDICARE: MS. JOAN JANELLE FERGUSON RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	2861	AL

General Provider Information

NPI Number	:	1881230993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JOAN JANELLE FERGUSON RD, LD

Provider Business Mailing Address
First Line	:	4912 CLAIRMONT AVE S
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35222-4421
Country	:	US
Telephone Number	:	205-602-9977
Fax Number	:	205-592-8835

Provider Business Practice Location Address
First Line	:	85 BAGBY DR STE 302
Second Line	:
City	:	HOMEWOOD
State	:	AL
Zip	:	35209-3735
Country	:	US
Telephone Number	:	205-602-9977
Fax Number	:	205-592-8835

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/24/2019
Last Update Date	:	11/24/2019

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