Basic Information
Provider Information
NPI: 1003149618
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CLARKE
FirstName: RANDI
MiddleName:  
NamePrefix: MRS.
NameSuffix:  
Credential: NP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1483 BEECH LN
Address2:  
City: EAST MEADOW
State: NY
PostalCode: 115543706
CountryCode: US
TelephoneNumber: 5164104497
FaxNumber:  
Practice Location
Address1: 300 COMMUNITY DR
Address2:  
City: MANHASSET
State: NY
PostalCode: 110303816
CountryCode: US
TelephoneNumber: 5164104497
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/14/2009
LastUpdateDate: 09/14/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LA2200XF3052261NYY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health

No ID Information.


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