Provider Demographics
NPI:1073768669
Name:CLARKE, ANGELA L (PN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:CLARKE
Suffix:
Gender:F
Credentials:PN
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 306
Mailing Address - Street 2:
Mailing Address - City:FORT HALL
Mailing Address - State:ID
Mailing Address - Zip Code:83203-0306
Mailing Address - Country:US
Mailing Address - Phone:208-238-2400
Mailing Address - Fax:208-238-5462
Practice Address - Street 1:PIMA DRIVE
Practice Address - Street 2:
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203-0306
Practice Address - Country:US
Practice Address - Phone:208-238-2400
Practice Address - Fax:208-238-5462
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPN 10202164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003399100Medicaid