Provider Demographics
NPI:1659396919
Name:CLARK, TERRI L (CRNA)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
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 354
Mailing Address - Street 2:
Mailing Address - City:RAYLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43943-0354
Mailing Address - Country:US
Mailing Address - Phone:740-633-2556
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6379
Practice Address - Country:US
Practice Address - Phone:304-243-3343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV44069367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0066297000Medicaid
OH2300147Medicaid
WV7166921Medicare ID - Type Unspecified