Provider Demographics
NPI:1043525025
Name:CLARK, SUSAN LOUISE (NP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LOUISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:5701 BOW POINTE DR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3198
Mailing Address - Country:US
Mailing Address - Phone:248-384-8300
Mailing Address - Fax:248-384-8309
Practice Address - Street 1:5701 BOW POINTE DR
Practice Address - Street 2:SUITE 225
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3198
Practice Address - Country:US
Practice Address - Phone:248-384-8300
Practice Address - Fax:248-384-8309
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4704201015363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health