Healthcare Provider Details

I. General information

NPI: 1497202279
Provider Name (Legal Business Name): DEVAN CLARK LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 N SNOW GOOSE DR
WASILLA AK
99654-2505
US

IV. Provider business mailing address

3540 N SNOW GOOSE DR
WASILLA AK
99654-2505
US

V. Phone/Fax

Practice location:
  • Phone: 419-961-3818
  • Fax:
Mailing address:
  • Phone: 419-961-3818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number107485
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMT-21190
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: