Provider Demographics
NPI:1275282279
Name:CLARK, ERICA
Entity Type:Individual
Prefix:
First Name:ERICA
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 1:785 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:DAWSON
Mailing Address - State:MN
Mailing Address - Zip Code:56232-2251
Mailing Address - Country:US
Mailing Address - Phone:612-735-3067
Mailing Address - Fax:
Practice Address - Street 1:785 HICKORY ST
Practice Address - Street 2:
Practice Address - City:DAWSON
Practice Address - State:MN
Practice Address - Zip Code:56232-2251
Practice Address - Country:US
Practice Address - Phone:612-735-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant