Basic Information
| Provider Information | |||||||||
| NPI: | 1508049594 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3883 AIRWAY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074734531 | ||||||||
| FaxNumber: | 7074734559 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 SONOMA AVE | ||||||||
| Address2: | 2A | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075265034 | ||||||||
| FaxNumber: | 7075453984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2007 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
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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 | 363L00000X | 16742 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.