Provider Demographics
NPI:1275008914
Name:CLARK, ANGELA MARIE (DNP, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DNP, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5255 MEMBERS PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-8381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5255 MEMBERS PKWY NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-8381
Practice Address - Country:US
Practice Address - Phone:507-218-3701
Practice Address - Fax:507-258-5503
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6229363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health