Provider Demographics
NPI:1841867652
Name:CLARK, SHELBY (BSN, RN)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7270 EDWARDS RD
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48744-9543
Mailing Address - Country:US
Mailing Address - Phone:810-397-2966
Mailing Address - Fax:
Practice Address - Street 1:2525 DEMILLE BLVD
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-3461
Practice Address - Country:US
Practice Address - Phone:810-245-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704328502364SL0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care