Provider Demographics
NPI:1710969498
Name:CLARK, JOAN MARIE (ANP)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:ANP
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 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-1019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6400 CLAYTON RD STE 302
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1850
Practice Address - Country:US
Practice Address - Phone:314-645-3370
Practice Address - Fax:314-645-0576
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2816742621363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO060065OtherEXCLUSIVE CHOICE
MO213137OtherBLUE CHOICE
MO500005275OtherRAILROAD MEDICARE
MO428933303Medicaid
072280OtherPROVIDER NUMBER
MO534842OtherHEALTHLINK
MO500005275OtherRAILROAD MEDICARE
MO060065OtherEXCLUSIVE CHOICE