Provider Demographics
NPI:1366867400
Name:CLARK, PAULA FAE (FNP)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:FAE
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-350-4606
Mailing Address - Fax:970-350-4692
Practice Address - Street 1:1555 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-9117
Practice Address - Country:US
Practice Address - Phone:970-304-6425
Practice Address - Fax:970-304-6416
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS76276363LF0000X
CO991016363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily