Provider Demographics
NPI:1255004131
Name:CLARKE, MADELINE RAE (RN)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:RAE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:RAE
Other - Last Name:AVERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 GLENWOOD CIR APT 27H
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-6732
Mailing Address - Country:US
Mailing Address - Phone:515-537-4788
Mailing Address - Fax:
Practice Address - Street 1:1260 MORENA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3850
Practice Address - Country:US
Practice Address - Phone:619-398-0355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95198067163WG0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice