Provider Demographics
NPI:1790003218
Name:CLARK, DEBRA LYNN ANN
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LYNN ANN
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 1:506 S STEEL ST
Mailing Address - Street 2:
Mailing Address - City:ONTONAGON
Mailing Address - State:MI
Mailing Address - Zip Code:49953-1554
Mailing Address - Country:US
Mailing Address - Phone:906-884-4430
Mailing Address - Fax:
Practice Address - Street 1:116 SECOND ST
Practice Address - Street 2:
Practice Address - City:GREENLAND
Practice Address - State:MI
Practice Address - Zip Code:49929
Practice Address - Country:US
Practice Address - Phone:906-883-3539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703059261164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse