Basic Information
| Provider Information | |||||||||
| NPI: | 1962954305 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | TERRI | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-BC, MSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 424 S MOORLAND DR | ||||||||
| Address2: | |||||||||
| City: | BATTLE CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490153944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692036516 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 842 COLUMBIA AVE E | ||||||||
| Address2: | |||||||||
| City: | BATTLE CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490145449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2697531710 | ||||||||
| FaxNumber: | 2697531717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2016 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 21623 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 4704279158 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.