Provider Demographics
NPI:1407692429
Name:CLUCK, AMY MCKELL (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MCKELL
Last Name:CLUCK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 N DOUGLASS ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MO
Mailing Address - Zip Code:63863-1512
Mailing Address - Country:US
Mailing Address - Phone:573-276-3873
Mailing Address - Fax:
Practice Address - Street 1:806 N DOUGLASS ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MO
Practice Address - Zip Code:63863-1512
Practice Address - Country:US
Practice Address - Phone:573-276-3873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024026240363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily