Provider Demographics
NPI:1952691461
Name:CLARK, MARY DENISE (CD(DONA))
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:DENISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CD(DONA)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 MILO CIR #B
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026
Mailing Address - Country:US
Mailing Address - Phone:303-604-4470
Mailing Address - Fax:
Practice Address - Street 1:1070 MILO CIR APT B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3089
Practice Address - Country:US
Practice Address - Phone:303-604-4470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCD(DONA)374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula