Provider Demographics
NPI:1598918690
Name:CLARK, MARY R (FNP, CNM)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:R
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:POINT REYES
Mailing Address - State:CA
Mailing Address - Zip Code:94956-0910
Mailing Address - Country:US
Mailing Address - Phone:415-663-8666
Mailing Address - Fax:415-663-9532
Practice Address - Street 1:3 SIXTH STREET
Practice Address - Street 2:
Practice Address - City:POINT REYES
Practice Address - State:CA
Practice Address - Zip Code:94956-0910
Practice Address - Country:US
Practice Address - Phone:415-663-8666
Practice Address - Fax:415-663-9532
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1140176B00000X
CA8074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No176B00000XOther Service ProvidersMidwife