Basic Information
| Provider Information | |||||||||
| NPI: | 1316908247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLANCY | ||||||||
| FirstName: | CHARLENE | ||||||||
| MiddleName: | CECILIA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1378 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211224720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103609454 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 N GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106057000 | ||||||||
| FaxNumber: | 4106057724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 11/05/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C02943 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.