Provider Demographics
NPI:1316908247
Name:CLANCY, CHARLENE CECILIA (PA-C)
Entity type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:CECILIA
Last Name:CLANCY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1378 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-4720
Mailing Address - Country:US
Mailing Address - Phone:410-360-9454
Mailing Address - Fax:
Practice Address - Street 1:10 N GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1524
Practice Address - Country:US
Practice Address - Phone:410-605-7000
Practice Address - Fax:410-605-7724
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC02943363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant