MEDICARE: MRS. TIFFANY FERGUSON FNP-BC

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	363LF0000X	Family Nurse Practitioner	209013649	IL
2	163W00000X	Registered Nurse	041358468	IL
3	363LF0000X	Family Nurse Practitioner	277000224	IL

General Provider Information

NPI Number	:	1962874032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIFFANY FERGUSON FNP-BC

Provider Business Mailing Address
First Line	:	2501 CHATHAM RD STE 4766
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-4188
Country	:	US
Telephone Number	:	847-220-4197
Fax Number	:

Provider Business Practice Location Address
First Line	:	2501 CHATHAM RD STE 4766
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-4188
Country	:	US
Telephone Number	:	847-220-4197
Fax Number	:

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

Provider Enumeration Date	:	10/28/2015
Last Update Date	:	09/12/2023

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