Provider Demographics
NPI:1366875007
Name:MCCLURE, CHARITY (APRN)
Entity type:Individual
Prefix:
First Name:CHARITY
Middle Name:
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:320 POMFRET STREET CSB 2
Mailing Address - Street 2:ATTN: CREDENTIALING DPT
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1836
Mailing Address - Country:US
Mailing Address - Phone:860-928-6541
Mailing Address - Fax:860-963-6450
Practice Address - Street 1:45 GREEN HOLLOW RD
Practice Address - Street 2:
Practice Address - City:DANIELSON
Practice Address - State:CT
Practice Address - Zip Code:06239-3509
Practice Address - Country:US
Practice Address - Phone:860-774-1255
Practice Address - Fax:860-928-8283
Is Sole Proprietor?:No
Enumeration Date:2013-08-16
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005450363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236346Medicaid