Provider Demographics
NPI:1174619480
Name:CLARKE, MARA M (NPC)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:M
Last Name:CLARKE
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 VALLEY VIEW DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6175
Mailing Address - Country:US
Mailing Address - Phone:309-757-1252
Mailing Address - Fax:
Practice Address - Street 1:515 VALLEY VIEW DR
Practice Address - Street 2:SUITE 103
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6175
Practice Address - Country:US
Practice Address - Phone:309-757-1252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK15671Medicare ID - Type Unspecified