Provider Demographics
NPI:1235624602
Name:CLARK, STACEY LYNN (RN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 W JOHN ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15522-1711
Mailing Address - Country:US
Mailing Address - Phone:814-617-0028
Mailing Address - Fax:
Practice Address - Street 1:9709 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:PA
Practice Address - Zip Code:15522
Practice Address - Country:US
Practice Address - Phone:814-652-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN696926163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management