Individual
MRS. RAE JEAN DE LEON FERGUSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
24743 W ILLINI ST, BUCKEYE, AZ 85326-3376
(623) 386-7631
Mailing address
24743 W ILLINI ST, BUCKEYE, AZ 85326-3376
(623) 386-7631
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
11264
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
171W00000X
—
AZ
Enumeration date
01/25/2007
Last updated
10/13/2009
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