Provider Demographics
NPI:1215556055
Name:CLARK, FELICIA ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:ANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 NE CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1901
Mailing Address - Country:US
Mailing Address - Phone:309-672-4670
Mailing Address - Fax:309-672-4669
Practice Address - Street 1:112 NE CRESCENT AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1901
Practice Address - Country:US
Practice Address - Phone:309-672-4670
Practice Address - Fax:309-672-4669
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-12
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program