Provider Demographics
NPI:1417116070
Name:CLARK, GEORGANNE M (CPM)
Entity Type:Individual
Prefix:MRS
First Name:GEORGANNE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 W 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-4905
Mailing Address - Country:US
Mailing Address - Phone:541-517-4268
Mailing Address - Fax:
Practice Address - Street 1:1009 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-4905
Practice Address - Country:US
Practice Address - Phone:541-517-4268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-08
Last Update Date:2008-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife