Provider Demographics
NPI:1245800317
Name:CLARK, JULIE (AFC LICENSEE)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:AFC LICENSEE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1453 CEDAR CT NE
Mailing Address - Street 2:
Mailing Address - City:KALKASKA
Mailing Address - State:MI
Mailing Address - Zip Code:49646-9704
Mailing Address - Country:US
Mailing Address - Phone:928-701-6859
Mailing Address - Fax:
Practice Address - Street 1:1453 CEDAR CT NE
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-9704
Practice Address - Country:US
Practice Address - Phone:928-701-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor