Basic Information
| Provider Information | |||||||||
| NPI: | 1033244942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | SHIRLEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | AS, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34703 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067640112 | ||||||||
| FaxNumber: | 2067640489 | ||||||||
| Practice Location | |||||||||
| Address1: | 9710 STATE AVE | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982702232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606531742 | ||||||||
| FaxNumber: | 3606532099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN00062095 | WA | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 7407083 | 05 | WA | MEDICAID |