Provider Demographics
NPI:1639969611
Name:CLARK, BETTYLOU
Entity type:Individual
Prefix:
First Name:BETTYLOU
Middle Name:
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 1:18176 CHRISTANNA HWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23868-2623
Mailing Address - Country:US
Mailing Address - Phone:607-267-0980
Mailing Address - Fax:
Practice Address - Street 1:18176 CHRISTANNA HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:VA
Practice Address - Zip Code:23868-2623
Practice Address - Country:US
Practice Address - Phone:607-267-0980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker