Provider Demographics
NPI:1881756310
Name:DEXTER, CLARISSE S (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:CLARISSE
Middle Name:S
Last Name:DEXTER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 VIRGINIA AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:375 WAMPANOAG TRL
Practice Address - Street 2:SUITE 102
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2232
Practice Address - Country:US
Practice Address - Phone:401-649-4010
Practice Address - Fax:401-649-4011
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP15609363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9095629Medicaid
RI007056293Medicare PIN