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General NPI Number Information
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NPI Number | 1639134562
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Entity Type | Individual
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Provider Name | ANGELIQUE CLEMSON D.O.
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Gender | Female
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Dates
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Enumeration Date | 04/20/2006
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 2023 CATO AVE STE 101
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City | STATE COLLEGE
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State | PA
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Zip | 16801-2765
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Country | US
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Telephone | 814-409-7377
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Fax |
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Provider Business Mailing Address
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Address Line | 808 S MAIN ST
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City | LEWISTOWN
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State | PA
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Zip | 17044-2537
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Country | US
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Telephone | 717-248-2619
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS010739L
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License Number State | PA
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