Provider Demographics
NPI:1467770974
Name:CLARK, NANCY SUZANNE (PT)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:SUZANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3787 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6148
Mailing Address - Country:US
Mailing Address - Phone:910-341-2444
Mailing Address - Fax:910-332-1519
Practice Address - Street 1:3787 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6148
Practice Address - Country:US
Practice Address - Phone:910-341-2444
Practice Address - Fax:910-332-1519
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist