Provider Demographics
NPI:1275705196
Name:ISLE OF WIGHT FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:ISLE OF WIGHT FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRATITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CECELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:757-332-6342
Mailing Address - Street 1:1807 SOUTH CHURCH STREET
Mailing Address - Street 2:SUITE 200 C
Mailing Address - City:SMITHFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23430
Mailing Address - Country:US
Mailing Address - Phone:757-332-6342
Mailing Address - Fax:757-357-9214
Practice Address - Street 1:1807 SOUTH CHURCH STREET
Practice Address - Street 2:SUITE 200 C
Practice Address - City:SMITHFIELD
Practice Address - State:VA
Practice Address - Zip Code:23430
Practice Address - Country:US
Practice Address - Phone:757-332-6342
Practice Address - Fax:757-357-9214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1023097615363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty