1730577016 NPI number — MRS. MARIBETH COLLARD CLARK CRNP

Table of content: MRS. MARIBETH COLLARD CLARK CRNP (NPI 1730577016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730577016 NPI number — MRS. MARIBETH COLLARD CLARK CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
MARIBETH
Provider Middle Name:
COLLARD
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COLLARD-CLARK
Provider Other First Name:
MARIBETH
Provider Other Middle Name:
KATHLEEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1730577016
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6801 AIRPORT BLVD
Provider Second Line Business Mailing Address:
HOSPITALIST DEPT.
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36608-3709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-639-5775
Provider Business Mailing Address Fax Number:
251-631-3581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6801 AIRPORT BLVD
Provider Second Line Business Practice Location Address:
HOSPITALIST DEPT.
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36608-3709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-639-5775
Provider Business Practice Location Address Fax Number:
251-631-3581
Provider Enumeration Date:
01/08/2015

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: 363LA2100X , with the licence number:  APRN11036078 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: 1-098071 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: APRN11036078 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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