Provider Demographics
NPI:1760555957
Name:CLARK, MAYA NICOLE (PHD, ACNP-BC)
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHD, ACNP-BC
Other - Prefix:
Other - First Name:MAYA
Other - Middle Name:NICOLE
Other - Last Name:CLARK-CUTAIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, ACNP-BC
Mailing Address - Street 1:700 SPRUCE ST
Mailing Address - Street 2:STE. 507
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4022
Mailing Address - Country:US
Mailing Address - Phone:215-829-8455
Mailing Address - Fax:215-829-8431
Practice Address - Street 1:700 SPRUCE ST
Practice Address - Street 2:STE. 507
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-4022
Practice Address - Country:US
Practice Address - Phone:215-829-8455
Practice Address - Fax:215-829-8431
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009244363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care