Provider Demographics
NPI:1700425311
Name:CLARK, SALLY E (LAC, RN)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:LAC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 LANDFALL LN
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-4312
Mailing Address - Country:US
Mailing Address - Phone:443-994-0087
Mailing Address - Fax:
Practice Address - Street 1:71 OLD MILL BOTTOM RD N STE 102
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21409-5446
Practice Address - Country:US
Practice Address - Phone:443-994-0087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02395171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist