Provider Demographics
NPI:1013905371
Name:CLARKE, SUSAN LEGENDER (DC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEGENDER
Last Name:CLARKE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:846 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-7110
Mailing Address - Country:US
Mailing Address - Phone:651-227-8776
Mailing Address - Fax:651-227-1055
Practice Address - Street 1:846 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-7110
Practice Address - Country:US
Practice Address - Phone:651-227-8776
Practice Address - Fax:651-227-1055
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2143111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350056171OtherRRCARE
MN041101001OtherMETROPOLITAN HEALTH PLAN
MN21316CLOtherBCBS CLINIC #
MN0N438CLOtherBCBS INDIVIDUAL PROVIDER
MN777027800Medicaid
MN20705OtherHEALTHPARTNERS ID
MN041101001OtherMETROPOLITAN HEALTH PLAN
MN0N438CLOtherBCBS INDIVIDUAL PROVIDER