Provider Demographics
NPI:1104569086
Name:MCCLUSKEY, KEALA
Entity type:Individual
Prefix:
First Name:KEALA
Middle Name:
Last Name:MCCLUSKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 1ST AVE SE APT 17
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-5607
Mailing Address - Country:US
Mailing Address - Phone:701-690-4968
Mailing Address - Fax:
Practice Address - Street 1:130 1ST AVE SE APT 17
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-5607
Practice Address - Country:US
Practice Address - Phone:701-690-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND64797376K00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376K00000XNursing Service Related ProvidersNurse's Aide