Healthcare Provider Details

I. General information

NPI: 1023703600
Provider Name (Legal Business Name): JACQUOLYNN LEE PLOUGHE BSN, RN, CRRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 RANDALLIA DR
FORT WAYNE IN
46805-4699
US

IV. Provider business mailing address

1282 SACRED OAK CT
FORT WAYNE IN
46818-0142
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-4172
  • Fax:
Mailing address:
  • Phone: 260-530-6126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28198300A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: