Provider Demographics
NPI:1831642438
Name:CLARKE, KATHRYN JANE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JANE
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 1:5270 BUDAPEST PL
Mailing Address - Street 2:
Mailing Address - City:DULLES
Mailing Address - State:VA
Mailing Address - Zip Code:20189-5269
Mailing Address - Country:US
Mailing Address - Phone:206-512-6556
Mailing Address - Fax:
Practice Address - Street 1:5270 BUDAPEST PL
Practice Address - Street 2:
Practice Address - City:DULLES
Practice Address - State:VA
Practice Address - Zip Code:20189-5269
Practice Address - Country:US
Practice Address - Phone:206-512-6556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-31
Last Update Date:2023-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001275652163W00000X
WARN 60141168163W00000X
VA0024175369363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMC3926271OtherDEA NUMBER