Provider Demographics
NPI:1083199269
Name:CLARK, TARA (PMHDNP)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PMHDNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 W LANTANA DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-3719
Mailing Address - Country:US
Mailing Address - Phone:480-330-8151
Mailing Address - Fax:
Practice Address - Street 1:600 S DOBSON RD STE E36
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5693
Practice Address - Country:US
Practice Address - Phone:480-471-8560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2018023496363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health