Provider Demographics
NPI:1851759872
Name:AMDUR-CLARK, STEPHANIE (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:AMDUR-CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 TIMBER CV APT D
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-3100
Mailing Address - Country:US
Mailing Address - Phone:716-548-1258
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-2548
Practice Address - Country:US
Practice Address - Phone:585-275-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-04
Last Update Date:2023-07-03
Deactivation Date:2019-09-10
Deactivation Code:
Reactivation Date:2019-09-30
Provider Licenses
StateLicense IDTaxonomies
MARN2299120163WH0200X
NY383057363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WH0200XNursing Service ProvidersRegistered NurseHome Health