Provider Demographics
NPI:1396012621
Name:CLARK, DENEAN ELIZABETH (RN)
Entity Type:Individual
Prefix:MRS
First Name:DENEAN
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20104 NYS RT 3
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5560
Mailing Address - Country:US
Mailing Address - Phone:315-779-7000
Mailing Address - Fax:315-779-7109
Practice Address - Street 1:20104 NYS RT 3
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5560
Practice Address - Country:US
Practice Address - Phone:315-779-7000
Practice Address - Fax:315-779-7109
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5666531163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool