Healthcare Provider Details

I. General information

NPI: 1780282004
Provider Name (Legal Business Name): CLAYTON DONALD HOUSE FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 07/11/2021
Certification Date: 07/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 ELECTRIC AVE
PORT HURON MI
48060-8127
US

IV. Provider business mailing address

620 N FAIRGROUNDS RD
IMLAY CITY MI
48444-9490
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-4747
  • Fax:
Mailing address:
  • Phone: 810-441-1347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704277180
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704277180
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: