MEDICARE: CARLEY MCCLOUD NP

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
1	363L00000X	Nurse Practitioner	209.014836	IL
2	390200000X	Student in an Organized Health Care Education/Training Program	RN2298925	MA
3	390200000X	Student in an Organized Health Care Education/Training Program	2015038431	MO
4	363L00000X	Nurse Practitioner	2016028855	MO

General Provider Information

NPI Number	:	1386003358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLEY MCCLOUD NP

Provider Business Mailing Address
First Line	:	402 E 4TH ST
Second Line	:	APT 105
City	:	DAVENPORT
State	:	IA
Zip	:	52801-1753
Country	:	US
Telephone Number	:	314-560-5711
Fax Number	:

Provider Business Practice Location Address
First Line	:	4350 7TH ST
Second Line	:
City	:	MOLINE
State	:	IL
Zip	:	61265-6870
Country	:	US
Telephone Number	:	309-517-1180
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/18/2016
Last Update Date	:	10/12/2016

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