Provider Demographics
NPI:1558707984
Name:CLARK, AMY MARIE (IDC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 BARNES RD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23437
Mailing Address - Country:US
Mailing Address - Phone:757-652-1981
Mailing Address - Fax:
Practice Address - Street 1:260 BARNES RD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23437
Practice Address - Country:US
Practice Address - Phone:757-652-1981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710-1002XOtherIDC