Basic Information
| Provider Information | |||||||||
| NPI: | 1619289683 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON-PAUL | ||||||||
| FirstName: | KENICE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 N DUNLAP ST | ||||||||
| Address2: | SUITE G145 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381054625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012875928 | ||||||||
| FaxNumber: | 9012876804 | ||||||||
| Practice Location | |||||||||
| Address1: | 848 ADAMS AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012877337 | ||||||||
| FaxNumber: | 9012875506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2010 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 4383 | GA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 54038 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.