Provider Demographics
NPI: | 1679579601 |
---|---|
Name: | CLEMONS, LINDA LOUISE (MSN, CRNP) |
Entity Type: | Individual |
Prefix: | |
First Name: | LINDA |
Middle Name: | LOUISE |
Last Name: | CLEMONS |
Suffix: | |
Gender: | F |
Credentials: | MSN, CRNP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1070 OLD NATIONAL PIKE |
Mailing Address - Street 2: | |
Mailing Address - City: | FREDERICKTOWN |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 15333-2114 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 724-632-6801 |
Mailing Address - Fax: | 724-632-6312 |
Practice Address - Street 1: | 37 HIGHLAND AVE |
Practice Address - Street 2: | |
Practice Address - City: | WASHINGTON |
Practice Address - State: | PA |
Practice Address - Zip Code: | 15301-4062 |
Practice Address - Country: | US |
Practice Address - Phone: | 724-223-1067 |
Practice Address - Fax: | 724-223-1088 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-23 |
Last Update Date: | 2024-05-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | TP003789B | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 1007288440104 | Medicaid | |
PA | 01582 | Other | HIGHMARK BLUE SHIELD |
PA | 014582 | Other | HGSA |
PA | 391902 | Other | NATIONAL GOVERNMENT SERVICES |