Provider Demographics
NPI:1104187798
Name:CLARKE, MICHELLE LYNN (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNN
Last Name:CLARKE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 ELM ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2951
Mailing Address - Country:US
Mailing Address - Phone:617-666-9577
Mailing Address - Fax:617-666-3190
Practice Address - Street 1:260 ELM ST
Practice Address - Street 2:SUITE 105
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-2951
Practice Address - Country:US
Practice Address - Phone:617-666-9577
Practice Address - Fax:617-666-3190
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2275315363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA002800301OtherMEDICARE PTAN