Provider Demographics
NPI:1760825392
Name:CLARK, MARY ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8634 OAKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-3763
Mailing Address - Country:US
Mailing Address - Phone:248-770-5940
Mailing Address - Fax:
Practice Address - Street 1:8634 OAKSIDE AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-3763
Practice Address - Country:US
Practice Address - Phone:248-770-5940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-13
Last Update Date:2013-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI9649374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula