Provider Demographics
NPI:1205969359
Name:CLARK, DOROTHY MARGARET
Entity type:Individual
Prefix:MR
First Name:DOROTHY
Middle Name:MARGARET
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 1:2575 CAPAC RD.
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MI
Mailing Address - Zip Code:48002-1203
Mailing Address - Country:US
Mailing Address - Phone:810-650-4230
Mailing Address - Fax:
Practice Address - Street 1:400 STODDARD RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MI
Practice Address - Zip Code:48062-2505
Practice Address - Country:US
Practice Address - Phone:810-392-2167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703051240164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse