Provider Demographics
NPI:1295365815
Name:CLARK, HEATHER ELAN (RN)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:ELAN
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 1:5721 HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:NY
Mailing Address - Zip Code:13080-9760
Mailing Address - Country:US
Mailing Address - Phone:315-689-5810
Mailing Address - Fax:315-689-3004
Practice Address - Street 1:5721 HAMILTON RD
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:NY
Practice Address - Zip Code:13080-9760
Practice Address - Country:US
Practice Address - Phone:315-689-5810
Practice Address - Fax:315-689-3004
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY661152163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool