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NPI Code Detail

MEDICARE: JACQUOLYNN LEE PLOUGHE BSN, RN, CRRN

MEDICARE: JACQUOLYNN LEE PLOUGHE BSN, RN, CRRN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1163W00000XRegistered Nurse28198300AIN

General Provider Information

NPI Number : 1023703600
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACQUOLYNN LEE PLOUGHE BSN, RN, CRRN
Provider Business Mailing Address
First Line : 1282 SACRED OAK CT
Second Line :
City : FORT WAYNE
State : IN
Zip : 46818-0142
Country : US
Telephone Number : 260-530-6126
Fax Number :
Provider Business Practice Location Address
First Line : 2200 RANDALLIA DR
Second Line :
City : FORT WAYNE
State : IN
Zip : 46805-4699
Country : US
Telephone Number : 260-266-4172
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/10/2023
Last Update Date : 04/10/2023

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