Provider Demographics
NPI:1942831987
Name:CLARKE, TONI E (MSN, APRN, AGNP-C)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:E
Last Name:CLARKE
Suffix:
Gender:F
Credentials:MSN, APRN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 731
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-0731
Mailing Address - Country:US
Mailing Address - Phone:832-449-0333
Mailing Address - Fax:
Practice Address - Street 1:3720 CHURCH ROCK ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4572
Practice Address - Country:US
Practice Address - Phone:505-722-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144683363LG0600X, 363LA2200X, 363LP2300X
NM60963363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health