Provider Demographics
NPI:1730530163
Name:CLARK, MOLLIE A
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:A
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 1:4400 MUNSON CT APT 205
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-6771
Mailing Address - Country:US
Mailing Address - Phone:561-670-8992
Mailing Address - Fax:
Practice Address - Street 1:4400 MUNSON CT APT 205
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-6771
Practice Address - Country:US
Practice Address - Phone:561-670-8992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist