Provider Demographics
NPI:1679040950
Name:CLARK, AUDREY DIANE (FNP-C)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:DIANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W RIVER ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:MA
Mailing Address - Zip Code:01364-1435
Mailing Address - Country:US
Mailing Address - Phone:978-544-7800
Mailing Address - Fax:
Practice Address - Street 1:450 W RIVER ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:MA
Practice Address - Zip Code:01364-1435
Practice Address - Country:US
Practice Address - Phone:978-544-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2311962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily