Provider Demographics
NPI:1336303106
Name:CLARK, CONNIE RUTH (ARNP)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:RUTH
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP
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 1492
Mailing Address - Street 2:
Mailing Address - City:STEVENSON
Mailing Address - State:WA
Mailing Address - Zip Code:98648-1492
Mailing Address - Country:US
Mailing Address - Phone:509-427-3850
Mailing Address - Fax:
Practice Address - Street 1:710 SW ROCK CREEK DR
Practice Address - Street 2:
Practice Address - City:STEVENSON
Practice Address - State:WA
Practice Address - Zip Code:98648-4418
Practice Address - Country:US
Practice Address - Phone:509-427-3850
Practice Address - Fax:509-427-0188
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60258145363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner