Provider Demographics
NPI:1477003366
Name:CLARK, DEANNA R (CFNP)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:R
Last Name:CLARK
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 MONTGOMERY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1103
Mailing Address - Country:US
Mailing Address - Phone:505-366-3635
Mailing Address - Fax:505-221-5429
Practice Address - Street 1:4225 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1103
Practice Address - Country:US
Practice Address - Phone:505-366-3635
Practice Address - Fax:505-221-5429
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03049363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily