Provider Demographics
NPI:1902421555
Name:CLARK, CHRISTY MARIE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 VANCE HILL RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-6406
Mailing Address - Country:US
Mailing Address - Phone:434-770-2205
Mailing Address - Fax:
Practice Address - Street 1:516 VANCE HILL RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-6406
Practice Address - Country:US
Practice Address - Phone:434-770-2205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024179442363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care