Healthcare Provider Details

I. General information

NPI: 1013594647
Provider Name (Legal Business Name): JONATHAN KYLE CLEGG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2124 SAINT NICHOLAS DR
HOPE MILLS NC
28348-8109
US

IV. Provider business mailing address

2124 SAINT NICHOLAS DR
HOPE MILLS NC
28348-8109
US

V. Phone/Fax

Practice location:
  • Phone: 917-945-5795
  • Fax:
Mailing address:
  • Phone: 917-945-5795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number160319
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: