Provider Demographics
NPI:1073064119
Name:CLARKE, MAKAYLA (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 662
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02813-0662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 LADY SLIPPER TRL
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02813-3414
Practice Address - Country:US
Practice Address - Phone:401-474-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI003972255A2300X
CT0010312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer