Provider Demographics
NPI:1427189836
Name:CLYDE, LANA MARIE
Entity Type:Individual
Prefix:MRS
First Name:LANA
Middle Name:MARIE
Last Name:CLYDE
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 1:215 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3924
Mailing Address - Country:US
Mailing Address - Phone:701-857-4410
Mailing Address - Fax:
Practice Address - Street 1:215 2ND ST SE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3924
Practice Address - Country:US
Practice Address - Phone:701-857-4410
Practice Address - Fax:701-857-4413
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND762235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND762Medicaid