Provider Demographics
NPI:1134680325
Name:CLARK, ERIN OLIVIA
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:OLIVIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3425
Mailing Address - Country:US
Mailing Address - Phone:910-678-0100
Mailing Address - Fax:
Practice Address - Street 1:1601 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3425
Practice Address - Country:US
Practice Address - Phone:910-678-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-02324208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice