Provider Demographics
NPI:1295512366
Name:CLARK, HALEY MICHELLE (FNP)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:MICHELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7757 MISSY CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-1930
Mailing Address - Country:US
Mailing Address - Phone:314-677-4994
Mailing Address - Fax:
Practice Address - Street 1:16216 BAXTER RD STE 100
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4778
Practice Address - Country:US
Practice Address - Phone:636-449-4700
Practice Address - Fax:636-449-2595
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023035149363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty