1396036570 NPI number — MRS. CLAIRE DEYOUNG CLEMENS

Table of content: MRS. CLAIRE DEYOUNG CLEMENS (NPI 1396036570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396036570 NPI number — MRS. CLAIRE DEYOUNG CLEMENS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEMENS
Provider First Name:
CLAIRE
Provider Middle Name:
DEYOUNG
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POPPE
Provider Other First Name:
CLAIRE
Provider Other Middle Name:
DEYOUNG
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396036570
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 HIGHLAND AVE
Provider Second Line Business Mailing Address:
MC 2433
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53792-1530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-662-0817
Provider Business Mailing Address Fax Number:
608-203-4544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 HIGHLAND AVE
Provider Second Line Business Practice Location Address:
MC 2433
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53792-1530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-662-0817
Provider Business Practice Location Address Fax Number:
608-203-4544
Provider Enumeration Date:
04/22/2011

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: 133V00000X , with the licence number:  01020890-RD , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01020890-RD . This is a "REGISTERED DIETITIAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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