Provider Demographics
NPI:1831322049
Name:CLARK, MICHELLE ELISE (ND)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ELISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 FORE DR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-8447
Mailing Address - Country:US
Mailing Address - Phone:941-224-6864
Mailing Address - Fax:
Practice Address - Street 1:537 FORE DR
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-8447
Practice Address - Country:US
Practice Address - Phone:941-224-6864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1126175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath