Provider Demographics
NPI:1407218100
Name:CLARK, CYNTHIA (LAC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 BISPHAM RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-5522
Mailing Address - Country:US
Mailing Address - Phone:941-923-9355
Mailing Address - Fax:
Practice Address - Street 1:2106 BISPHAM RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-5522
Practice Address - Country:US
Practice Address - Phone:941-923-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3067171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist