Basic Information
Provider Information | |||||||||
NPI: | 1427202092 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FERGUSON | ||||||||
FirstName: | AMBER | ||||||||
MiddleName: | JANE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BOWE | ||||||||
OtherFirstName: | AMBER | ||||||||
OtherMiddleName: | JANE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1836 SOUTH AVE | ||||||||
Address2: |   | ||||||||
City: | LA CROSSE | ||||||||
State: | WI | ||||||||
PostalCode: | 546015429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087827300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3525 MONTEREY DR | ||||||||
Address2: |   | ||||||||
City: | ST LOUIS PARK | ||||||||
State: | MN | ||||||||
PostalCode: | 554165275 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9529936200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2008 | ||||||||
LastUpdateDate: | 03/19/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2109 | WI | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.