Provider Demographics
NPI:1790380988
Name:CLARK, CAITLIN MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6016 KAYTON ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-4328
Mailing Address - Country:US
Mailing Address - Phone:512-364-4081
Mailing Address - Fax:
Practice Address - Street 1:234 CROOKED CREEK PKWY STE 200
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-8506
Practice Address - Country:US
Practice Address - Phone:919-544-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5013848363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily