Provider Demographics
NPI:1942805577
Name:CLARK, ROCHELLE CRYSTAL (NP)
Entity Type:Individual
Prefix:MS
First Name:ROCHELLE
Middle Name:CRYSTAL
Last Name: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 1:1707 JUDY WAY
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-1832
Mailing Address - Country:US
Mailing Address - Phone:443-453-6174
Mailing Address - Fax:
Practice Address - Street 1:1707 JUDY WAY
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:MD
Practice Address - Zip Code:21040-1832
Practice Address - Country:US
Practice Address - Phone:443-453-6174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR218420363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily