Provider Demographics
NPI:1275985210
Name:CLARK, ALEXANDER (LPN)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-2353
Mailing Address - Country:US
Mailing Address - Phone:917-470-0152
Mailing Address - Fax:
Practice Address - Street 1:181 RIDGE RD
Practice Address - Street 2:
Practice Address - City:VALLEY COTTAGE
Practice Address - State:NY
Practice Address - Zip Code:10989-2353
Practice Address - Country:US
Practice Address - Phone:917-470-0152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-01
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315947164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse