Provider Demographics
NPI:1578273900
Name:CLARKE, SHANEEKA
Entity Type:Individual
Prefix:
First Name:SHANEEKA
Middle Name:
Last Name:CLARKE
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 1:2870 FAIRHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:TOBYHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18466-3765
Mailing Address - Country:US
Mailing Address - Phone:272-336-9147
Mailing Address - Fax:
Practice Address - Street 1:970 ROUTE 196 UNIT 6
Practice Address - Street 2:
Practice Address - City:TOBYHANNA
Practice Address - State:PA
Practice Address - Zip Code:18466-8208
Practice Address - Country:US
Practice Address - Phone:272-336-9157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN307649164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse