Healthcare Provider Details

I. General information

NPI: 1003653916
Provider Name (Legal Business Name): NICHOLE MCCLOY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12432 MORRIS DIDO NEWARK RD
FORT WORTH TX
76179-9206
US

IV. Provider business mailing address

12432 MORRIS DIDO NEWARK RD
FORT WORTH TX
76179-9206
US

V. Phone/Fax

Practice location:
  • Phone: 303-960-2422
  • Fax:
Mailing address:
  • Phone: 303-960-2422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number
License Number State

VIII. Authorized Official

Name: NICHOLE MCCLOY
Title or Position: OWNER
Credential: RN IBCLC
Phone: 303-960-2422