Provider Demographics
NPI:1740698935
Name:CLARK, MARY CHRISTINE (RCP, IBCLC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RCP, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2774 230TH ST
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:WI
Mailing Address - Zip Code:54006-3421
Mailing Address - Country:US
Mailing Address - Phone:715-808-2603
Mailing Address - Fax:
Practice Address - Street 1:2774 230TH ST
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:WI
Practice Address - Zip Code:54006-3421
Practice Address - Country:US
Practice Address - Phone:715-808-2603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI27-2024772OtherEIN