Provider Demographics
NPI:1942335641
Name:CLARK, CHRISTINE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 LEHIGH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-3880
Mailing Address - Country:US
Mailing Address - Phone:610-289-0114
Mailing Address - Fax:610-289-4282
Practice Address - Street 1:1501 LEHIGH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-3880
Practice Address - Country:US
Practice Address - Phone:610-289-0114
Practice Address - Fax:610-289-4282
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL-007066171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor