Provider Demographics
NPI:1215441092
Name:CLARKE-PENNANT, MARCIA CAROLINE
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:CAROLINE
Last Name:CLARKE-PENNANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4770 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10470-1104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 TIBBITS AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10606-2438
Practice Address - Country:US
Practice Address - Phone:914-287-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA249451AP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA999999999999OtherDO NOT HAVE A NPI NUMBER