Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
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

26630 BARTON RD APT 2023
REDLANDS CA
92373-4329
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 Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: