=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548205180
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER MICHELLE CLOUGHERTY ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 W ELIZABETH ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28328-4822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-280-6138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 406 STEWART AVE
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28328-2937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 762
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------