Provider Demographics
NPI:1558703538
Name:CLARK, DEBORAH JEAN
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:JEAN
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 1:51 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03055-3705
Mailing Address - Country:US
Mailing Address - Phone:603-525-3335
Mailing Address - Fax:866-611-5548
Practice Address - Street 1:3 ELMWOOD RD
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:NH
Practice Address - Zip Code:03449-5629
Practice Address - Country:US
Practice Address - Phone:603-525-3335
Practice Address - Fax:866-611-5548
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHFDC2111150174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist