Healthcare Provider Details

I. General information

NPI: 1366171563
Provider Name (Legal Business Name): CONNIE CLOUGHER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 TRINITY PL
MISHAWAKA IN
46545-5006
US

IV. Provider business mailing address

1226 S WALNUT ST
LA PORTE IN
46350-6336
US

V. Phone/Fax

Practice location:
  • Phone: 574-272-9000
  • Fax:
Mailing address:
  • Phone: 219-851-3220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number28106474A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: