1023636867 NPI number — MRS. LENA DANIELLE CLOUSE PHARMD

Table of content: MRS. LENA DANIELLE CLOUSE PHARMD (NPI 1023636867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023636867 NPI number — MRS. LENA DANIELLE CLOUSE PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLOUSE
Provider First Name:
LENA
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
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:
1023636867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12806 FAWN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR LAKE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46303-8675
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-771-0102
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
GENOA HEALTHCARE LLC
Provider Second Line Business Practice Location Address:
8555 TAFT STREET
Provider Business Practice Location Address City Name:
MERRILLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-769-8171
Provider Business Practice Location Address Fax Number:
219-769-8176
Provider Enumeration Date:
07/08/2020

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: 183500000X , with the licence number:  26022500A , 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)





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