Provider Demographics
NPI:1255617080
Name:CLARK, CHRISTOPHER MATTHEW (RN)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MATTHEW
Last Name:CLARK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16200 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1103
Mailing Address - Country:US
Mailing Address - Phone:586-873-8607
Mailing Address - Fax:586-416-6705
Practice Address - Street 1:16200 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1103
Practice Address - Country:US
Practice Address - Phone:586-873-8607
Practice Address - Fax:586-416-6705
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704280192163WP0809X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult