Provider Demographics
NPI:1437368214
Name:CLARKE, MANDA LYNNE (APRN)
Entity Type:Individual
Prefix:
First Name:MANDA
Middle Name:LYNNE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MANDA
Other - Middle Name:LYNNE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1232 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:NE
Mailing Address - Zip Code:69301-3655
Mailing Address - Country:US
Mailing Address - Phone:308-762-3095
Mailing Address - Fax:
Practice Address - Street 1:2107 BOX BUTTE AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-4415
Practice Address - Country:US
Practice Address - Phone:308-762-7244
Practice Address - Fax:308-762-6657
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE110849363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily