Provider Demographics
NPI:1750563086
Name:CLEMSON, MAR Y LOUISE (RNCS)
Entity type:Individual
Prefix:
First Name:MAR Y
Middle Name:LOUISE
Last Name:CLEMSON
Suffix:
Gender:F
Credentials:RNCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-2118
Mailing Address - Country:US
Mailing Address - Phone:757-622-6673
Mailing Address - Fax:757-622-6673
Practice Address - Street 1:602 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508-2118
Practice Address - Country:US
Practice Address - Phone:757-622-6673
Practice Address - Fax:757-622-6673
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1193801163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08982OtherMEDICARE
VAP00071810OtherRAILROAD
VA101867OtherANTHEM GROUP
VA101868OtherANTHEM INDIVIDUAL
VA101867OtherANTHEM GROUP