Provider Demographics
NPI:1124081070
Name:CLUTTERBUCK, ELAINE (CNM)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:CLUTTERBUCK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14204-2275
Mailing Address - Country:US
Mailing Address - Phone:716-847-6610
Mailing Address - Fax:716-854-3052
Practice Address - Street 1:397 LOUISIANA ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14204-2275
Practice Address - Country:US
Practice Address - Phone:716-847-6610
Practice Address - Fax:716-854-3052
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000223367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010252101OtherUNIVERA
NY2012804OtherFIDELIS
NY5008733OtherIHA
NY00466393Medicaid
NY005600462OtherBCBS
DD4317Medicare ID - Type Unspecified
R99256Medicare UPIN