Basic Information
| Provider Information | |||||||||
| NPI: | 1831698158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLOUSER | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DONATELLI | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 248 ZIEGLER RD | ||||||||
| Address2: | |||||||||
| City: | LEESPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 195339413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107800903 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2607 KEISER BLVD | ||||||||
| Address2: | |||||||||
| City: | WYOMISSING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196103338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107433139 | ||||||||
| FaxNumber: | 6107433143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2018 | ||||||||
| LastUpdateDate: | 07/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP018561 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.