Provider Demographics
NPI:1639681000
Name:CLARK, MELISSA SUE (ARNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:RAMEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2222 EAST ST STE 305
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-2066
Mailing Address - Country:US
Mailing Address - Phone:925-686-1230
Mailing Address - Fax:
Practice Address - Street 1:2222 EAST ST STE 305
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2066
Practice Address - Country:US
Practice Address - Phone:925-686-1230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007947363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty