Provider Demographics
NPI:1629321211
Name:CLARKE, MARISA (RN)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 843
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-0021
Mailing Address - Country:US
Mailing Address - Phone:470-899-6852
Mailing Address - Fax:
Practice Address - Street 1:887 W MARIETTA ST NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-5252
Practice Address - Country:US
Practice Address - Phone:888-772-0076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY664254163W00000X
GARN267349363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse