1124036421 NPI number — AMANDA CLARKE CRNP

Table of content: AMANDA CLARKE CRNP (NPI 1124036421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124036421 NPI number — AMANDA CLARKE CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARKE
Provider First Name:
AMANDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124036421
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 CAMDEN AVE
Provider Second Line Business Mailing Address:
HH180
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21801-6837
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-543-6262
Provider Business Mailing Address Fax Number:
410-548-4101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
951A MOUNT HERMON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21804-5105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-548-2700
Provider Business Practice Location Address Fax Number:
410-548-2608
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  R170955 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R170955 . This is a "LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com