Basic Information
| Provider Information | |||||||||
| NPI: | 1356689103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | MIKI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776347 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022725052 | ||||||||
| FaxNumber: | 5026296217 | ||||||||
| Practice Location | |||||||||
| Address1: | 4950 NORTON HEALTHCARE BOULEVARD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402412848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023946350 | ||||||||
| FaxNumber: | 5023946363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2013 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3007704 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100234060 | 05 | KY | MEDICAID | 201140060 | 05 | IN | MEDICAID | 144543 | 01 | KY | SIHO - NNIKY | OTHER | 000000802747 | 01 | KY | ANTHEM - NNIKY | OTHER | 50047890 | 01 | KY | PASSPORT - NNI | OTHER |