Provider Demographics
NPI:1053617589
Name:CLARK, AMIE MELISSA (CRNA)
Entity type:Individual
Prefix:
First Name:AMIE
Middle Name:MELISSA
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AMIE
Other - Middle Name:MELISSA
Other - Last Name:SPRUELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3975 WILMINGTON AVE
Mailing Address - Street 2:APT A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-3250
Mailing Address - Country:US
Mailing Address - Phone:314-280-8157
Mailing Address - Fax:
Practice Address - Street 1:13515 BARRETT PARKWAY DR
Practice Address - Street 2:SUITE 170
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-5870
Practice Address - Country:US
Practice Address - Phone:314-775-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.389801163W00000X
FL086232367500000X
MO2016017057367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse