Basic Information
| Provider Information | |||||||||
| NPI: | 1346541786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
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| Practice Location | |||||||||
| Address1: | 930 N 14TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473624311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655212450 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2010 | ||||||||
| LastUpdateDate: | 11/14/2019 | ||||||||
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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 | 363L00000X | 71003386A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201002830 | 05 | IN | MEDICAID | 945350168 | 01 | MEDICARE | OTHER |