Provider Demographics
NPI:1619435310
Name:RIES-CLARK, JENNIFER GAYLE (FNPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:GAYLE
Last Name:RIES-CLARK
Suffix:
Gender:F
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8009 W SALTER DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-4440
Mailing Address - Country:US
Mailing Address - Phone:602-663-8127
Mailing Address - Fax:
Practice Address - Street 1:8009 W SALTER DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-4440
Practice Address - Country:US
Practice Address - Phone:602-663-8127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ219824363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ219824OtherARIZONA ADVANCED PRACTICE LICENCE
AZRN157294OtherARIZONA STATE BOARD OF NURSING