Provider Demographics
NPI:1376305631
Name:MBA, CLARISE (NP)
Entity Type:Individual
Prefix:
First Name:CLARISE
Middle Name:
Last Name:MBA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:CLARISE
Other - Middle Name:
Other - Last Name:MBA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4432 MARRIOTTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-6127
Mailing Address - Country:US
Mailing Address - Phone:240-855-3422
Mailing Address - Fax:
Practice Address - Street 1:4432 MARRIOTTSVILLE RD
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-6127
Practice Address - Country:US
Practice Address - Phone:240-855-3422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR215393363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily