Basic Information
| Provider Information | |||||||||
| NPI: | 1124036421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 CAMDEN AVE | ||||||||
| Address2: | HH180 | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218016837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105436262 | ||||||||
| FaxNumber: | 4105484101 | ||||||||
| Practice Location | |||||||||
| Address1: | 951A MOUNT HERMON RD | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218045105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105482700 | ||||||||
| FaxNumber: | 4105482608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 02/14/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | R170955 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | R170955 | 01 | MD | LICENSE | OTHER |