Provider Demographics
NPI:1932619616
Name:CLARK, ANNA MARIA (WHNP)
Entity Type:Individual
Prefix:MRS
First Name:ANNA
Middle Name:MARIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:MS
Other - First Name:ANNA
Other - Middle Name:MARIA
Other - Last Name:BRERETON-HUBBARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2174 CEDAR FOREST CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-7201
Mailing Address - Country:US
Mailing Address - Phone:314-795-8748
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 4017B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8269
Practice Address - Country:US
Practice Address - Phone:314-488-2134
Practice Address - Fax:314-251-4234
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2017039220363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program