Provider Demographics
NPI:1346532751
Name:CLARK, CAROL W (RN, BSN)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:W
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SOUTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLOINS
Mailing Address - State:CO
Mailing Address - Zip Code:80523
Mailing Address - Country:US
Mailing Address - Phone:970-491-7121
Mailing Address - Fax:
Practice Address - Street 1:600 SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80523
Practice Address - Country:US
Practice Address - Phone:970-491-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO84-6000-545163WC1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1400XNursing Service ProvidersRegistered NurseCollege Health