Provider Demographics
NPI:1689918450
Name:CLARK, JULIE KAYE (IBLCE)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:KAYE
Last Name:CLARK
Suffix:
Gender:F
Credentials:IBLCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 BUCKEYSTOWN PIKE
Mailing Address - Street 2:P. O. BOX
Mailing Address - City:BUCKEYSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21717
Mailing Address - Country:US
Mailing Address - Phone:301-246-2556
Mailing Address - Fax:
Practice Address - Street 1:1301 MOTTER AVENUE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701
Practice Address - Country:US
Practice Address - Phone:301-246-2556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11216325174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN