Provider Demographics
NPI:1386290609
Name:MCCLOUD, CORISA (CNP)
Entity type:Individual
Prefix:
First Name:CORISA
Middle Name:
Last Name:MCCLOUD
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 LAWNVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2611
Mailing Address - Country:US
Mailing Address - Phone:740-704-2349
Mailing Address - Fax:
Practice Address - Street 1:1025 LAWNVIEW AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2611
Practice Address - Country:US
Practice Address - Phone:740-704-2349
Practice Address - Fax:407-042-3497
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025435363LF0000X
OHCNP.025435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPRN.CNP.025435OtherLICENSE NUMBER