Provider Demographics
NPI:1952144107
Name:CLARKE, EULALEE A
Entity type:Individual
Prefix:
First Name:EULALEE
Middle Name:A
Last Name: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 1:1652 SEAGIRT BLVD
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4511
Mailing Address - Country:US
Mailing Address - Phone:646-312-9532
Mailing Address - Fax:
Practice Address - Street 1:1652 SEAGIRT BLVD
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4511
Practice Address - Country:US
Practice Address - Phone:646-312-9532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292655-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse