Provider Demographics
NPI:1154685469
Name:CLYBURN, DOUGLAS (RN)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:CLYBURN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-1326
Mailing Address - Country:US
Mailing Address - Phone:347-937-0238
Mailing Address - Fax:
Practice Address - Street 1:23 YORK AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-1326
Practice Address - Country:US
Practice Address - Phone:347-937-0238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY568854163W00000X, 163WA0400X, 163WC0400X, 163WC2100X, 163WD0400X, 163WG0000X, 163WH0200X, 163WH1000X, 163WI0600X, 163WM0705X, 163WN1003X, 163WP0000X, 163WW0000X, 163WX1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC2100XNursing Service ProvidersRegistered NurseContinence Care
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No163WI0600XNursing Service ProvidersRegistered NurseInfection Control
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support
No163WP0000XNursing Service ProvidersRegistered NursePain Management
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163WX1500XNursing Service ProvidersRegistered NurseOstomy Care