Provider Demographics
NPI:1982685954
Name:CLARK, MARYANNE C (PMHNP)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E EARLL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2647
Mailing Address - Country:US
Mailing Address - Phone:602-865-0008
Mailing Address - Fax:
Practice Address - Street 1:2715 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1106
Practice Address - Country:US
Practice Address - Phone:602-264-4331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11153363LF0000X
AZAP11154363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ376867Medicaid
NMQ06427Medicare ID - Type UnspecifiedCNP