Provider Demographics
NPI:1740440809
Name:CLARK, NANCY S (CNM)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 CALLE DE ALEGRA
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88006
Mailing Address - Country:US
Mailing Address - Phone:575-556-8150
Mailing Address - Fax:575-556-8159
Practice Address - Street 1:390 CALLE DE ALEGRA
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3280
Practice Address - Country:US
Practice Address - Phone:575-556-8150
Practice Address - Fax:505-556-8159
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4923176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM95147Medicaid
NM95147Medicaid