Provider Demographics
NPI:1598307530
Name:CLARK, AUDREY R (CNP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:R
Last Name:CLARK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:WOFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7936 BRADY RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1246
Mailing Address - Country:US
Mailing Address - Phone:505-352-4838
Mailing Address - Fax:
Practice Address - Street 1:7936 BRADY RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1246
Practice Address - Country:US
Practice Address - Phone:505-352-4838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM57708363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care