Basic Information
| Provider Information | |||||||||
| NPI: | 1437368214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | MANDA | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITE | ||||||||
| OtherFirstName: | MANDA | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1232 E 8TH ST | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 693013655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3087623095 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2107 BOX BUTTE AVE | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 693014415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3087627244 | ||||||||
| FaxNumber: | 3087626657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 110849 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.