Provider Demographics
NPI:1417600842
Name:CLARK, PEYTON ROSE
Entity Type:Individual
Prefix:
First Name:PEYTON
Middle Name:ROSE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10220 SPRING CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SPOTSYLVANIA
Mailing Address - State:VA
Mailing Address - Zip Code:22553-4044
Mailing Address - Country:US
Mailing Address - Phone:540-424-1260
Mailing Address - Fax:
Practice Address - Street 1:800 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22807-0001
Practice Address - Country:US
Practice Address - Phone:540-568-6211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program