Basic Information
| Provider Information | |||||||||
| NPI: | 1962771568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | CAROLINE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 RINDGE TER | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021401826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174605394 | ||||||||
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| Practice Location | |||||||||
| Address1: | 31 HEATH ST | ||||||||
| Address2: | |||||||||
| City: | JAMAICA PLAIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021301650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175236400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2011 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
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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 | 363LP0808X | RN2273680 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.