Provider Demographics
NPI:1932722907
Name:CLARK, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
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 1:814 W BELLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MI
Mailing Address - Zip Code:48655-1616
Mailing Address - Country:US
Mailing Address - Phone:989-284-7258
Mailing Address - Fax:
Practice Address - Street 1:1147 S BAY DR
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9318
Practice Address - Country:US
Practice Address - Phone:989-284-7258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-25
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201003815225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist