Provider Demographics
NPI:1265764930
Name:CLARKE, JUDY GOODROAD (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:GOODROAD
Last Name:CLARKE
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93893 LEEHMANN LN
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-9003
Mailing Address - Country:US
Mailing Address - Phone:541-947-4010
Mailing Address - Fax:
Practice Address - Street 1:93893 LEEHMANN LN
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-9003
Practice Address - Country:US
Practice Address - Phone:541-947-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR088003027RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse