Provider Demographics
NPI:1871099036
Name:CLEGHORN, MARY JANE (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:CLEGHORN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5563 CONCORD CIR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30507-8704
Mailing Address - Country:US
Mailing Address - Phone:770-530-2137
Mailing Address - Fax:
Practice Address - Street 1:5563 CONCORD CIR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30507-8704
Practice Address - Country:US
Practice Address - Phone:770-530-2137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN106126163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA90M0619454Medicaid