Provider Demographics
NPI:1952451445
Name:CLARK, NANCY A
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:A
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 1:609 STATE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4562
Mailing Address - Country:US
Mailing Address - Phone:360-658-6071
Mailing Address - Fax:360-658-6271
Practice Address - Street 1:609 STATE AVE STE C
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4562
Practice Address - Country:US
Practice Address - Phone:360-658-6071
Practice Address - Fax:360-658-6271
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016620225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0179409Medicare UPIN