Provider Demographics
NPI:1942372966
Name:CLARK, TERRI LEE (RN)
Entity Type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 N RYNDERS ST
Mailing Address - Street 2:
Mailing Address - City:GRAND CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54914-1614
Mailing Address - Country:US
Mailing Address - Phone:920-993-8445
Mailing Address - Fax:920-993-8445
Practice Address - Street 1:1505 N RYNDERS ST
Practice Address - Street 2:
Practice Address - City:GRAND CHUTE
Practice Address - State:WI
Practice Address - Zip Code:54914-1614
Practice Address - Country:US
Practice Address - Phone:920-993-8445
Practice Address - Fax:920-993-8445
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38276400Medicaid