Provider Demographics
NPI:1982293874
Name:CLARK, ELISABETH DANIELLE
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:DANIELLE
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 1:11551 KALI OKA RD
Mailing Address - Street 2:
Mailing Address - City:EIGHT MILE
Mailing Address - State:AL
Mailing Address - Zip Code:36613-8729
Mailing Address - Country:US
Mailing Address - Phone:334-360-1155
Mailing Address - Fax:
Practice Address - Street 1:106A SARALAND LOOP
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-2419
Practice Address - Country:US
Practice Address - Phone:251-675-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS13072390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program