Provider Demographics
NPI:1629709811
Name:CLARK, SAMANTHA N
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:N
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:PO BOX 21772
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7053
Mailing Address - Country:US
Mailing Address - Phone:307-638-1979
Mailing Address - Fax:833-207-0301
Practice Address - Street 1:215 WALTERSCHEID BLVD APT D203
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-2641
Practice Address - Country:US
Practice Address - Phone:307-760-9911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator