Basic Information
| Provider Information | |||||||||
| NPI: | 1699184515 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | TERRANCE | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | AGPC NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 CONGRESS STREET | ||||||||
| Address2: | SUITE 104 EXPERIENCE WELLNESS CENTERS LLC | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137320040 | ||||||||
| FaxNumber: | 4137327007 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 CONGRESS STREET | ||||||||
| Address2: | SUITE 104 EXPERIENCE WELLNESS CENTERS LLC | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137320040 | ||||||||
| FaxNumber: | 4137327007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2014 | ||||||||
| LastUpdateDate: | 08/05/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN2281720 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | RN2281720 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LP2300X | RN2281720 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.