1346541786 NPI number — LAURA E CLARKE NP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346541786 NPI number — LAURA E CLARKE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARKE
Provider First Name:
LAURA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1346541786
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 N TILLOTSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUNCIE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47304-3988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-288-1928
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 N 14TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW CASTLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47362-4311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-521-2450
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2010

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: 363L00000X , with the licence number:  71003386A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 201002830 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 945350168 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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