Provider Demographics
NPI:1417483553
Name:CLARK, MACEY (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:MACEY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 SUNSET DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1200
Mailing Address - Country:US
Mailing Address - Phone:541-663-3150
Mailing Address - Fax:
Practice Address - Street 1:710 SUNSET DR
Practice Address - Street 2:SUITE E
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1200
Practice Address - Country:US
Practice Address - Phone:541-962-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201241211RN363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics