Provider Demographics
NPI:1609313428
Name:MIRIAM CLARK
Entity Type:Organization
Organization Name:MIRIAM CLARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, RN
Authorized Official - Phone:781-235-3182
Mailing Address - Street 1:35 CHESTERTON RD
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-1106
Mailing Address - Country:US
Mailing Address - Phone:781-235-3182
Mailing Address - Fax:
Practice Address - Street 1:35 CHESTERTON RD
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-1106
Practice Address - Country:US
Practice Address - Phone:781-235-3182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2284844261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center