Provider Demographics
NPI:1376161349
Name:CLARKE-MONTAQUE, CAROL MARJORIE
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:MARJORIE
Last Name:CLARKE-MONTAQUE
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 1:3 GREEN MANOR DR
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-3519
Mailing Address - Country:US
Mailing Address - Phone:860-869-4055
Mailing Address - Fax:
Practice Address - Street 1:3 GREEN MANOR DR
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-3519
Practice Address - Country:US
Practice Address - Phone:860-869-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTR43870163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool