Provider Demographics
NPI:1518756949
Name:CLARK, RACHEL LEEANN (PA-C)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:LEEANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 N RYNDERS ST
Mailing Address - Street 2:
Mailing Address - City:GRAND CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54914-1614
Mailing Address - Country:US
Mailing Address - Phone:920-594-1219
Mailing Address - Fax:
Practice Address - Street 1:2502 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:ASHWAUBENON
Practice Address - State:WI
Practice Address - Zip Code:54304-5252
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8279-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant