1861586182 NPI number — CAROLINE CLARK ARNP

Table of content: CAROLINE CLARK ARNP (NPI 1861586182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861586182 NPI number — CAROLINE CLARK ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
CAROLINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861586182
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOPPENISH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98948-0190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-865-6175
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 E NOB HILL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98901-3534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-248-3334
Provider Business Practice Location Address Fax Number:
509-453-6144
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP30006884 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5262CL . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0192516 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9643461 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9643461 . This is a "CHPW" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8940611 . This is a "CRIMEVICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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