Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0202X | Pediatric Cardiologist | 74968 | GA |
N | 2080P0203X | Pediatric Critical Care Doctor | 50214 | WI |
NPI | 1104973999 |
---|---|
Provider Name | Dr. Shanelle A. Clarke |
First Address | Atlanta, GA 30341-5510 |
Second Address | Atlanta, GA 30322-5510 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2007 |
Last Update Date | 22/01/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
003170465A | (05) | GA |
1104973999 | (05) | WI |
34768400 | (05) | WI |