Provider Demographics
NPI:1053956870
Name:FERGUSON, KATELYN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 COURTENAY DR STE 1302
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8911
Mailing Address - Country:US
Mailing Address - Phone:843-792-9704
Mailing Address - Fax:
Practice Address - Street 1:25 COURTENAY DR
Practice Address - Street 2:SUITE 1302
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8911
Practice Address - Country:US
Practice Address - Phone:843-792-9704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1811133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered