Provider Demographics
NPI:1124092655
Name:CLOUGH, EVELYN LOUISE (ANP, CDCII)
Entity type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:LOUISE
Last Name:CLOUGH
Suffix:
Gender:F
Credentials:ANP, CDCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1015
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-1015
Mailing Address - Country:US
Mailing Address - Phone:907-262-5324
Mailing Address - Fax:907-260-7464
Practice Address - Street 1:44539 STERLING HWY
Practice Address - Street 2:SUITE 105
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7938
Practice Address - Country:US
Practice Address - Phone:907-262-5324
Practice Address - Fax:907-260-7464
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1091101YA0400X
AK668363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP4248Medicaid
AKNP4248Medicaid