Provider Demographics
NPI:1508049594
Name:CLARK, KAREN MARIE (NP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3883 AIRWAY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1670
Mailing Address - Country:US
Mailing Address - Phone:707-473-4531
Mailing Address - Fax:707-473-4559
Practice Address - Street 1:1140 SONOMA AVE
Practice Address - Street 2:2A
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4817
Practice Address - Country:US
Practice Address - Phone:707-526-5034
Practice Address - Fax:707-545-3984
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16742363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner