Provider Demographics
NPI:1801841606
Name:CLARK, STACY SUZANNE (DC)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:SUZANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 EBCO CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980
Mailing Address - Country:US
Mailing Address - Phone:540-946-2311
Mailing Address - Fax:540-946-2312
Practice Address - Street 1:6 EBCO CIRCLE
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980
Practice Address - Country:US
Practice Address - Phone:540-946-2311
Practice Address - Fax:540-946-2312
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555884111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U68446Medicare UPIN
350001196Medicare ID - Type Unspecified