MEDICARE: MRS. CRYSTAL ANN CLOUGH RN

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	163WC1500X	Community Health Registered Nurse	349166	NY

General Provider Information

NPI Number	:	1881848299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL ANN CLOUGH RN

Provider Business Mailing Address
First Line	:	4272 DENEVE RD
Second Line	:
City	:	CINCINNATUS
State	:	NY
Zip	:	13040-2130
Country	:	US
Telephone Number	:	607-849-3525
Fax Number	:

Provider Business Practice Location Address
First Line	:	4272 DENEVE RD
Second Line	:
City	:	CINCINNATUS
State	:	NY
Zip	:	13040-2130
Country	:	US
Telephone Number	:	607-849-3525
Fax Number	:

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

Provider Enumeration Date	:	11/12/2008
Last Update Date	:	08/12/2019

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