Provider Demographics
NPI:1700297421
Name:CLARK, CANDICE A
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:A
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 1:152 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BELCHERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01007-9604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:152 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BELCHERTOWN
Practice Address - State:MA
Practice Address - Zip Code:01007-9604
Practice Address - Country:US
Practice Address - Phone:413-530-3647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN212758163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300237Medicaid