Provider Demographics
NPI:1740518646
Name:CLARK, RACHEL L (NP-C)
Entity type:Individual
Prefix:MS
First Name:RACHEL
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HO PLZ
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14853-3102
Mailing Address - Country:US
Mailing Address - Phone:607-255-5155
Mailing Address - Fax:
Practice Address - Street 1:110 HO PLZ
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14853-3102
Practice Address - Country:US
Practice Address - Phone:607-255-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-03
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337544363LF0000X
OHCOA.1193-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCOA.11193-NPOtherCERTIFIED NURSE PRACTITIONER
OHRN.355902-COA1OtherRN