Provider Demographics
NPI:1689269177
Name:HAILEY A. CLARK FNP-C LLC
Entity type:Organization
Organization Name:HAILEY A. CLARK FNP-C LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HAILEY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:208-223-1049
Mailing Address - Street 1:4060 DUANE ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-1846
Mailing Address - Country:US
Mailing Address - Phone:208-223-1049
Mailing Address - Fax:
Practice Address - Street 1:814 PANCHERI DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3344
Practice Address - Country:US
Practice Address - Phone:208-223-1049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service