Provider Demographics
NPI:1568549921
Name:CLARKE, KIMBERLY C (CRNA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:C
Last Name:CLARKE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:C
Other - Last Name:HODGSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9422
Mailing Address - Country:US
Mailing Address - Phone:207-283-7040
Mailing Address - Fax:207-283-7850
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9422
Practice Address - Country:US
Practice Address - Phone:207-283-7040
Practice Address - Fax:207-283-7850
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER050962367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
HOME1874Medicare ID - Type Unspecified