Provider Demographics
NPI:1770067696
Name:CLUCKEY, RHEANNA LOUISE
Entity type:Individual
Prefix:
First Name:RHEANNA
Middle Name:LOUISE
Last Name:CLUCKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 BEAUMONT PL APT A
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-5477
Mailing Address - Country:US
Mailing Address - Phone:469-688-8146
Mailing Address - Fax:
Practice Address - Street 1:70 N COUNTRY RD STE 102
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2161
Practice Address - Country:US
Practice Address - Phone:631-938-6999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY757374163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse