Healthcare Provider Details

I. General information

NPI: 1750563086
Provider Name (Legal Business Name): MAR Y LOUISE CLEMSON RNCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 MASSACHUSETTS AVE
NORFOLK VA
23508-2118
US

IV. Provider business mailing address

602 MASSACHUSETTS AVE
NORFOLK VA
23508-2118
US

V. Phone/Fax

Practice location:
  • Phone: 757-622-6673
  • Fax: 757-622-6673
Mailing address:
  • Phone: 757-622-6673
  • Fax: 757-622-6673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number1193801
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: