Provider Demographics
NPI:1023097615
Name:CLARKE, CECELIA (NP-C, MD)
Entity type:Individual
Prefix:
First Name:CECELIA
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:NP-C, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 GRANDVILLE ARCH
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23430-6266
Mailing Address - Country:US
Mailing Address - Phone:757-332-6342
Mailing Address - Fax:
Practice Address - Street 1:1820 E WARM SPRINGS RD STE 140
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-4593
Practice Address - Country:US
Practice Address - Phone:702-779-3956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166730363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1023097615Medicaid
VA00X690172Medicare UPIN