Provider Demographics
NPI:1700493608
Name:CLARK-DELOGU, ANN ELIZABETH
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:ELIZABETH
Last Name:CLARK-DELOGU
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 1:11720 SE ALDER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-3868
Mailing Address - Country:US
Mailing Address - Phone:206-902-7168
Mailing Address - Fax:
Practice Address - Street 1:608 LANCASTER DR SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-5643
Practice Address - Country:US
Practice Address - Phone:503-877-1995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4330175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath