Basic Information
| Provider Information | |||||||||
| NPI: | 1366875007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCLURE | ||||||||
| FirstName: | CHARITY | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 POMFRET STREET CSB 2 | ||||||||
| Address2: | ATTN: CREDENTIALING DPT | ||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609286541 | ||||||||
| FaxNumber: | 8609636450 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 GREEN HOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | DANIELSON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062393509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607741255 | ||||||||
| FaxNumber: | 8609288283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2013 | ||||||||
| LastUpdateDate: | 10/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 005450 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 004236346 | 05 | CT | MEDICAID |