Provider Demographics
NPI:1275602633
Name:CLARKE, JANELISE S (NP)
Entity Type:Individual
Prefix:
First Name:JANELISE
Middle Name:S
Last Name:CLARKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JANELISE
Other - Middle Name:S
Other - Last Name:GUNNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3070 WESTERN BLUFFS BLVD
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59106-2209
Mailing Address - Country:US
Mailing Address - Phone:208-251-0095
Mailing Address - Fax:
Practice Address - Street 1:14355 MIRANDA WAY
Practice Address - Street 2:
Practice Address - City:LOS ALTOS HILLS
Practice Address - State:CA
Practice Address - Zip Code:94022-2032
Practice Address - Country:US
Practice Address - Phone:650-546-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP661A363L00000X
MTNUR-APRN-LIC-125338363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00393459OtherRAILROAD MEDICARE
ID806937600Medicaid
ID000010160650OtherREGENCE
ID300936OtherALTIUS HEALTH PLANS
ID000010160650OtherREGENCE
ID806937600Medicaid