Provider Demographics
NPI:1275066540
Name:CLARKE, TELESE
Entity Type:Individual
Prefix:
First Name:TELESE
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 E CAMP WISDOM RD
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-2706
Mailing Address - Country:US
Mailing Address - Phone:972-709-3448
Mailing Address - Fax:972-709-3451
Practice Address - Street 1:328 E CAMP WISDOM RD
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116
Practice Address - Country:US
Practice Address - Phone:972-709-3448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1871924993OtherDAY HAB