Provider Demographics
NPI:1396729331
Name:CLARK, DEBORAH A (RN, CS, NP)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, CS, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BISHOPS LN
Mailing Address - Street 2:
Mailing Address - City:LYNNFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01940-1340
Mailing Address - Country:US
Mailing Address - Phone:781-334-3173
Mailing Address - Fax:
Practice Address - Street 1:3 ESSEX GREEN DR
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2913
Practice Address - Country:US
Practice Address - Phone:781-307-6094
Practice Address - Fax:781-334-4196
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA153934363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANS0377Medicare ID - Type Unspecified
PO6221Medicare UPIN