Provider Demographics
NPI:1336216589
Name:NEAGLE, MILDRED CLARK (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:CLARK
Last Name:NEAGLE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HENRICO AREA MENTAL HEALTH AND RETARDATION SERVICES
Mailing Address - Street 2:10299 WOODMAN RD
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060
Mailing Address - Country:US
Mailing Address - Phone:804-727-8435
Mailing Address - Fax:804-727-8364
Practice Address - Street 1:HENRICO AREA MENTAL HEALTH AND RETARDATION SERVICES
Practice Address - Street 2:10299 WOODMAN RD
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060
Practice Address - Country:US
Practice Address - Phone:804-727-8435
Practice Address - Fax:804-727-8364
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017138700363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAR36803Medicare UPIN