Provider Demographics
NPI:1770177941
Name:CLARK, ERIN NOELLE
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:NOELLE
Last Name:CLARK
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 1:275 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-7231
Mailing Address - Country:US
Mailing Address - Phone:541-660-0169
Mailing Address - Fax:
Practice Address - Street 1:495 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5681
Practice Address - Country:US
Practice Address - Phone:541-476-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202101839NP-PP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics