Healthcare Provider Details

I. General information

NPI: 1457669483
Provider Name (Legal Business Name): RAIMONDA KATHRYN CLARKE ANP/GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 N MAIN ST
LEEDS MA
01053-9764
US

IV. Provider business mailing address

421 N MAIN ST
LEEDS MA
01053-9764
US

V. Phone/Fax

Practice location:
  • Phone: 134-584-4040
  • Fax:
Mailing address:
  • Phone: 134-584-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number305448
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number340775
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: