Provider Demographics
NPI:1093524274
Name:CLARKE, COLLEEN (LPN)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:4930 DARIEN DR
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-5802
Mailing Address - Country:US
Mailing Address - Phone:585-491-0056
Mailing Address - Fax:
Practice Address - Street 1:4930 DARIEN DR
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-5802
Practice Address - Country:US
Practice Address - Phone:585-491-0056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335906164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse