1114040979 NPI number — MRS. CASSANDRA ANN CLARK B.A.

Table of content: MRS. CASSANDRA ANN CLARK B.A. (NPI 1114040979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114040979 NPI number — MRS. CASSANDRA ANN CLARK B.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
CASSANDRA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
B.A.
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:
1114040979
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 502
Provider Second Line Business Mailing Address:
815 SE TRINITY
Provider Business Mailing Address City Name:
WILBUR
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99185-0502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-647-5730
Provider Business Mailing Address Fax Number:
509-725-4901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
49 PARK STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99122-0421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-725-4900
Provider Business Practice Location Address Fax Number:
509-725-4901
Provider Enumeration Date:
04/09/2007

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: 101YM0800X , with the licence number:  RC00023755 , 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)





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