Basic Information
Provider Information | |||||||||
NPI: | 1063800886 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLEMENS | ||||||||
FirstName: | JOHANNA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 314 S WELLS ST | ||||||||
Address2: |   | ||||||||
City: | SISTERSVILLE | ||||||||
State: | WV | ||||||||
PostalCode: | 261751098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3046522611 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 350 14TH AVE | ||||||||
Address2: |   | ||||||||
City: | SKAGWAY | ||||||||
State: | AK | ||||||||
PostalCode: | 998400537 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9079832255 | ||||||||
FaxNumber: | 9079832793 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/31/2014 | ||||||||
LastUpdateDate: | 10/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 282NR1301X | APRN62719NP | WV | N |   | Hospitals | General Acute Care Hospital | Rural | 363LF0000X | 131324 | AK | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.