Provider Demographics
NPI:1659413615
Name:CLARKE WALLEN, NICOLA (PMHNP)
Entity Type:Individual
Prefix:
First Name:NICOLA
Middle Name:
Last Name:CLARKE WALLEN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3307 DUNWOOD RIDGE TER
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-1259
Mailing Address - Country:US
Mailing Address - Phone:202-569-2638
Mailing Address - Fax:
Practice Address - Street 1:3261 OLD WASHINGTON RD STE 2020
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3231
Practice Address - Country:US
Practice Address - Phone:301-960-8930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR190596363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty