Provider Demographics
NPI:1619567690
Name:CLARK, STACIE LYNN
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E PATTERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:PA
Mailing Address - Zip Code:16001-6337
Mailing Address - Country:US
Mailing Address - Phone:724-991-8337
Mailing Address - Fax:
Practice Address - Street 1:115 E PATTERSON AVE
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-6337
Practice Address - Country:US
Practice Address - Phone:724-991-8337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN106688L164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse