Provider Demographics
NPI:1710146220
Name:CLARK, LISA M (CPNP-AC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIVERSITY HOSP MEDICAL CENTER STONY BROOK
Mailing Address - Street 2:DEPT PEDIATRICS HSC 11TH FLOOR
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8111
Mailing Address - Country:US
Mailing Address - Phone:631-444-2967
Mailing Address - Fax:631-444-6212
Practice Address - Street 1:UNIVERSITY HOSP MEDICAL CENTER STONY BRK
Practice Address - Street 2:DEPT PEDIATRICS HSC 11TH FLOOR
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-2967
Practice Address - Fax:631-444-6212
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380567363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY380567OtherNYS LICIENCE NUMBER