Basic Information
| Provider Information | |||||||||
| NPI: | 1033799069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | BARBARA | ||||||||
| MiddleName: | JOAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN61149827 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NELSON | ||||||||
| OtherFirstName: | BARBARA | ||||||||
| OtherMiddleName: | JOAN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN61149827 | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7440 W MARGINAL WAY S | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981084141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067681990 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1960 THOMPSON DR | ||||||||
| Address2: | |||||||||
| City: | SEDRO WOOLLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982845007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608563186 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2021 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN61149824 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |
No ID Information.