Provider Demographics
NPI:1104584192
Name:WILSON-CLARKE, SERITA RENEE
Entity type:Individual
Prefix:
First Name:SERITA
Middle Name:RENEE
Last Name:WILSON-CLARKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 POPES HILL ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02122-3310
Mailing Address - Country:US
Mailing Address - Phone:617-733-0556
Mailing Address - Fax:
Practice Address - Street 1:398 NEPONSET AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02122-3134
Practice Address - Country:US
Practice Address - Phone:617-323-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2359781163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse