Provider Demographics
NPI:1972694735
Name:WARDLAW, CLARICE NICHOLE (CNM)
Entity Type:Individual
Prefix:MRS
First Name:CLARICE
Middle Name:NICHOLE
Last Name:WARDLAW
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:CLARICE
Other - Middle Name:NICHOLE
Other - Last Name:CHILDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:3590 TOWNE POINT RD UNIT 6791
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-1339
Mailing Address - Country:US
Mailing Address - Phone:757-439-7406
Mailing Address - Fax:757-859-0007
Practice Address - Street 1:3333 STATION HOUSE RD STE B
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-2515
Practice Address - Country:US
Practice Address - Phone:833-526-4448
Practice Address - Fax:757-859-0007
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177177367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175627201Medicaid
VA1972694735Medicaid
SCMW0175Medicaid