Provider Demographics
NPI:1952059677
Name:CLARK, EDNA (CD(DONA))
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CD(DONA)
Other - Prefix:
Other - First Name:ANDE
Other - Middle Name:
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CD(DONA)
Mailing Address - Street 1:1029 LONNIE CLARK RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-7319
Mailing Address - Country:US
Mailing Address - Phone:850-524-7776
Mailing Address - Fax:
Practice Address - Street 1:1029 LONNIE CLARK RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-7319
Practice Address - Country:US
Practice Address - Phone:850-524-7776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14404374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula