Provider Demographics
NPI:1235465014
Name:CLARK, MARYBETH
Entity Type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
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 1:37 DIETZ ST
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-1882
Mailing Address - Country:US
Mailing Address - Phone:607-432-2252
Mailing Address - Fax:607-432-7206
Practice Address - Street 1:37 DIETZ ST
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-1882
Practice Address - Country:US
Practice Address - Phone:607-432-2252
Practice Address - Fax:607-432-7206
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176488-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY176488-1Medicaid