Provider Demographics
NPI:1629228093
Name:CLARK, MYRA LESLIE (PHD, NP-C)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:LESLIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 RANSON CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-8622
Mailing Address - Country:US
Mailing Address - Phone:434-293-0660
Mailing Address - Fax:
Practice Address - Street 1:7048 MECHANICSVILLE TPKE
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23111-7101
Practice Address - Country:US
Practice Address - Phone:804-730-9498
Practice Address - Fax:804-569-7967
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170893363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily