Provider Demographics
NPI:1548631575
Name:CLARK, AMY (NP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:613 S MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-2856
Mailing Address - Country:US
Mailing Address - Phone:252-413-0720
Mailing Address - Fax:252-413-0854
Practice Address - Street 1:613 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2856
Practice Address - Country:US
Practice Address - Phone:252-413-0720
Practice Address - Fax:252-413-0854
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC209899NMedicare PIN