Provider Demographics
NPI:1326165234
Name:CLARK, LINDA C (RN, CDE)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 208
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:AZ
Mailing Address - Zip Code:85550-0208
Mailing Address - Country:US
Mailing Address - Phone:928-475-7205
Mailing Address - Fax:928-475-7370
Practice Address - Street 1:223 CIBEQUE CIRCLE ROAD
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:AZ
Practice Address - Zip Code:85550-0208
Practice Address - Country:US
Practice Address - Phone:928-475-7205
Practice Address - Fax:928-475-7370
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN046813163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator