Provider Demographics
NPI:1891976544
Name:CLARKE, CARLA ADELLE (RN)
Entity Type:Individual
Prefix:MS
First Name:CARLA
Middle Name:ADELLE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 EAST 220TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-1201
Mailing Address - Country:US
Mailing Address - Phone:718-654-0438
Mailing Address - Fax:
Practice Address - Street 1:76 WHITTIER DRIVE
Practice Address - Street 2:
Practice Address - City:THORNWOOD
Practice Address - State:NY
Practice Address - Zip Code:10594-1714
Practice Address - Country:US
Practice Address - Phone:914-747-3292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5617191163W00000X
NY2601141164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02073870Medicaid