Basic Information
| Provider Information | |||||||||
| NPI: | 1770775959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | D'JUANA | ||||||||
| MiddleName: | LASHA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APN-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 CONGRESS LN | ||||||||
| Address2: | |||||||||
| City: | SOUTH RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088822580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7324327891 | ||||||||
| FaxNumber: | 9736554159 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 HOW LN | ||||||||
| Address2: | |||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089013653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327458600 | ||||||||
| FaxNumber: | 7328288929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2007 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 26NJ00135800 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.