Provider Demographics
NPI:1124036421
Name:CLARKE, AMANDA (CRNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 CAMDEN AVE
Mailing Address - Street 2:HH180
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-6837
Mailing Address - Country:US
Mailing Address - Phone:410-543-6262
Mailing Address - Fax:410-548-4101
Practice Address - Street 1:951A MOUNT HERMON RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5105
Practice Address - Country:US
Practice Address - Phone:410-548-2700
Practice Address - Fax:410-548-2608
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR170955363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR170955OtherLICENSE