Provider Demographics
NPI:1295430700
Name:CLARK, ELIZABETH ANNE (MD, MPH)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 COPPER HILL ROAD
Mailing Address - Street 2:PO BOX 169
Mailing Address - City:GLEN HAVEN
Mailing Address - State:CO
Mailing Address - Zip Code:80532
Mailing Address - Country:US
Mailing Address - Phone:970-372-8832
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:SUITE 601
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-7874
Practice Address - Fax:704-355-5619
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program