Healthcare Provider Details

I. General information

NPI: 1912837865
Provider Name (Legal Business Name): MARK LAWRENCE CLELLAND CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 W PARK PL
COEUR D ALENE ID
83814-2785
US

IV. Provider business mailing address

PO BOX 1387
HAYDEN ID
83835-1387
US

V. Phone/Fax

Practice location:
  • Phone: 208-620-5250
  • Fax: 208-667-2638
Mailing address:
  • Phone: 208-415-0299
  • Fax: 208-625-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3281736
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3281736
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: