Healthcare Provider Details

I. General information

NPI: 1265057327
Provider Name (Legal Business Name): JONATHAN MICHAEL CLOUGH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2020
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 N ORANGE BLOSSOM TRL
KISSIMMEE FL
34744-2316
US

IV. Provider business mailing address

2450 N ORANGE BLOSSOM TRL
KISSIMMEE FL
34744-2316
US

V. Phone/Fax

Practice location:
  • Phone: 407-846-4343
  • Fax:
Mailing address:
  • Phone: 407-846-4343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704393276
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR915554
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9599547
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: