MEDICARE: MAR Y LOUISE CLEMSON RNCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse	1193801	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C08982	OTHER	VA	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00071810	OTHER	VA	RAILROAD
3	101867	OTHER	VA	ANTHEM GROUP
4	101868	OTHER	VA	ANTHEM INDIVIDUAL

General Provider Information

NPI Number	:	1750563086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAR Y LOUISE CLEMSON RNCS

Provider Business Mailing Address
First Line	:	602 MASSACHUSETTS AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23508-2118
Country	:	US
Telephone Number	:	757-622-6673
Fax Number	:	757-622-6673

Provider Business Practice Location Address
First Line	:	602 MASSACHUSETTS AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23508-2118
Country	:	US
Telephone Number	:	757-622-6673
Fax Number	:	757-622-6673

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2007
Last Update Date	:	03/26/2008

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