Provider Demographics
NPI:1881863488
Name:CLARK, DIANE K (ACNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:K
Last Name:CLARK
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:9427 SW BARNES RD
Practice Address - Street 2:STE 595
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6640
Practice Address - Country:US
Practice Address - Phone:503-216-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT278877-4405363LA2100X, 364SC0200X
OR201150003NP363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00957594OtherRR MEDICARE
OR500631611Medicaid
ORR158384Medicare PIN
OR500631611Medicaid