Provider Demographics
NPI:1043880644
Name:CLANCY, KEVIN JAMES
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
Last Name:CLANCY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 COACH HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4280
Mailing Address - Country:US
Mailing Address - Phone:262-364-9193
Mailing Address - Fax:
Practice Address - Street 1:3811 OHARA ST RM 803
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2561
Practice Address - Country:US
Practice Address - Phone:262-364-9193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program