Basic Information
| Provider Information | |||||||||
| NPI: | 1053926246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | NIKKOL | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2611 WAYNE AVE | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454201833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372567801 | ||||||||
| FaxNumber: | 9372591129 | ||||||||
| Practice Location | |||||||||
| Address1: | 2611 WAYNE AVE | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454201833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372567801 | ||||||||
| FaxNumber: | 9372591129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2020 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN.171081.MEDS-IV | OH | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.