Provider Demographics
NPI:1992487425
Name:CLARKE, WENDY RENEA
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:RENEA
Last Name:CLARKE
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 1:29653 ANCHOR CROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-9594
Mailing Address - Country:US
Mailing Address - Phone:251-633-0663
Mailing Address - Fax:
Practice Address - Street 1:6701 AIRPORT BLVD STE B222
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-6700
Practice Address - Country:US
Practice Address - Phone:251-633-0663
Practice Address - Fax:251-266-3601
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-097135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily