Provider Demographics
NPI:1376138289
Name:CLARK, ABIGAIL COLLETT
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:COLLETT
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ABIGAIL
Other - Middle Name:COLLETT
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-757-3500
Mailing Address - Fax:856-365-4088
Practice Address - Street 1:1600 HADDON AVE FL 6
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3101
Practice Address - Country:US
Practice Address - Phone:856-757-3500
Practice Address - Fax:856-365-4088
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NJ25MP00684900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant