=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730433921
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EARNESTINE GAINER-CLEMENTS ED.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2012
-----------------------------------------------------
Last Update Date | 11/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1122 JENKS AVE
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32401-2439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-683-1887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1841 MALLARD DR
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32404-2951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-874-1387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------