Provider Demographics
NPI:1386003358
Name:MCCLOUD, CARLEY (NP)
Entity Type:Individual
Prefix:
First Name:CARLEY
Middle Name:
Last Name:MCCLOUD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 E 4TH ST
Mailing Address - Street 2:APT 105
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52801-1753
Mailing Address - Country:US
Mailing Address - Phone:314-560-5711
Mailing Address - Fax:
Practice Address - Street 1:4350 7TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6870
Practice Address - Country:US
Practice Address - Phone:309-517-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-18
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014836363L00000X
MARN2298925390200000X
MO2015038431390200000X
MO2016028855363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program