Provider Demographics
NPI:1013215334
Name:CLARK, TERI LYNN (ONCOLOGY ESTHETICIAN)
Entity Type:Individual
Prefix:MRS
First Name:TERI
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:ONCOLOGY ESTHETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 SW 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-4390
Mailing Address - Country:US
Mailing Address - Phone:352-237-6096
Mailing Address - Fax:352-236-6099
Practice Address - Street 1:2530 SW 27TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-4390
Practice Address - Country:US
Practice Address - Phone:352-237-6096
Practice Address - Fax:352-236-6099
Is Sole Proprietor?:No
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFB9716027174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist