Provider Demographics
NPI:1558585760
Name:CLARK, LUCY ANN (LUCY CLARK)
Entity Type:Individual
Prefix:MS
First Name:LUCY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LUCY CLARK
Other - Prefix:
Other - First Name:LUCY
Other - Middle Name:GEISLER
Other - Last Name:HOPKINS-CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LUCY CLARK, LMT
Mailing Address - Street 1:7011 GATORBONE RD
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE HEIGHTS
Mailing Address - State:FL
Mailing Address - Zip Code:32656-8195
Mailing Address - Country:US
Mailing Address - Phone:352-235-2125
Mailing Address - Fax:352-473-9572
Practice Address - Street 1:432 2ND ST S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6764
Practice Address - Country:US
Practice Address - Phone:352-235-2125
Practice Address - Fax:352-473-9572
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0013899172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC7459OtherBCBS PROVIDER