Provider Demographics
NPI:1982128351
Name:CLOUSE, MARY ANGELA (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANGELA
Last Name:CLOUSE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 E LINDA LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-6112
Mailing Address - Country:US
Mailing Address - Phone:480-290-3509
Mailing Address - Fax:
Practice Address - Street 1:1922 E LINDA LN
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-6112
Practice Address - Country:US
Practice Address - Phone:480-290-3509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61372083363LF0000X
COC-APN.0004738-C-NP363LF0000X
UT13396889-4405363LF0000X
AZAP10428363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
98873OtherKAREO