Healthcare Provider Details

I. General information

NPI: 1760620801
Provider Name (Legal Business Name): AMY B CLARKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2009
Last Update Date: 02/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 29, BLACK COAL DRIVE
FT. WASHAKIE WY
82514
US

IV. Provider business mailing address

PO BOX 128
FORT WASHAKIE WY
82514-0128
US

V. Phone/Fax

Practice location:
  • Phone: 307-335-5940
  • Fax: 307-332-3949
Mailing address:
  • Phone: 307-332-6846
  • Fax: 307-332-3949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number15074
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: