MEDICARE: CHASITY CLOUGH FNP

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	207Q00000X	Family Medicine Physician	1000920	TX
2	363LF0000X	Family Nurse Practitioner	1000920	TX

General Provider Information

NPI Number	:	1922703438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHASITY CLOUGH FNP

Provider Business Mailing Address
First Line	:	36 PEMBERTON CV
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38305-5514
Country	:	US
Telephone Number	:	731-394-1145
Fax Number	:

Provider Business Practice Location Address
First Line	:	7514 KINGSLEY ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77087-4412
Country	:	US
Telephone Number	:	731-394-1145
Fax Number	:

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

Provider Enumeration Date	:	04/03/2023
Last Update Date	:	05/08/2023

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