Provider Demographics
NPI:1104174119
Name:DURDEN, CLARICE O Y (LPN)
Entity type:Individual
Prefix:MRS
First Name:CLARICE
Middle Name:O Y
Last Name:DURDEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:CLARICE
Other - Middle Name:OY
Other - Last Name:BRADEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:7709 CONNECTICUT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-5903
Mailing Address - Country:US
Mailing Address - Phone:216-502-8205
Mailing Address - Fax:
Practice Address - Street 1:7709 CONNECTICUT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-5903
Practice Address - Country:US
Practice Address - Phone:216-502-8205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-22
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN149816164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0070898Medicaid