Provider Demographics
NPI:1801913801
Name:CLARKE, MARY KIMBERLY (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KIMBERLY
Last Name:CLARKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CAROLINA MEADOWS
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-8510
Mailing Address - Country:US
Mailing Address - Phone:919-942-4014
Mailing Address - Fax:919-942-0377
Practice Address - Street 1:500 CAROLINA MEADOWS
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-8471
Practice Address - Country:US
Practice Address - Phone:919-370-7102
Practice Address - Fax:919-942-0377
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0900036363LA2200X
NC900035363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2592857AOtherMEDICARE PIN PTAN
NC811995OtherPARTNERS
561380014GOtherHUMANA