Provider Demographics
NPI:1821271008
Name:CLARK, ROSE M (NP)
Entity Type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:ROSE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CFNP
Mailing Address - Street 1:489 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-2825
Mailing Address - Country:US
Mailing Address - Phone:304-622-2708
Mailing Address - Fax:304-623-9302
Practice Address - Street 1:489 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2825
Practice Address - Country:US
Practice Address - Phone:304-622-2708
Practice Address - Fax:304-623-9302
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24387363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health