Provider Demographics
NPI:1376067124
Name:CLARK, MICHELLE E (APRN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W SENECA ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:NE
Mailing Address - Zip Code:68869-1363
Mailing Address - Country:US
Mailing Address - Phone:308-452-3203
Mailing Address - Fax:308-452-3794
Practice Address - Street 1:104 W SENECA ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:NE
Practice Address - Zip Code:68869-1363
Practice Address - Country:US
Practice Address - Phone:308-452-3203
Practice Address - Fax:308-452-3794
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112270363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner