Provider Demographics
NPI:1346622479
Name:CLARK, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 KIMBALL HILL RD
Mailing Address - Street 2:
Mailing Address - City:WEST TOPSHAM
Mailing Address - State:VT
Mailing Address - Zip Code:05086
Mailing Address - Country:US
Mailing Address - Phone:802-439-6196
Mailing Address - Fax:
Practice Address - Street 1:47 KIMBALL HILL RD
Practice Address - Street 2:MAIL SLOT 41
Practice Address - City:WEST TOPSHAM
Practice Address - State:VT
Practice Address - Zip Code:05086
Practice Address - Country:US
Practice Address - Phone:802-439-6196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT026.0009203174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN