Healthcare Provider Details

I. General information

NPI: 1366875007
Provider Name (Legal Business Name): CHARITY MCCLURE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 GREEN HOLLOW RD
DANIELSON CT
06239-3509
US

IV. Provider business mailing address

320 POMFRET STREET CSB 2 ATTN: CREDENTIALING DPT
PUTNAM CT
06260-1836
US

V. Phone/Fax

Practice location:
  • Phone: 860-774-1255
  • Fax: 860-928-8283
Mailing address:
  • Phone: 860-928-6541
  • Fax: 860-963-6450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number005450
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: