Healthcare Provider Details

I. General information

NPI: 1033964796
Provider Name (Legal Business Name): SARAH CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E 17TH ST
AMMON ID
83406-6669
US

IV. Provider business mailing address

1621 E 49TH S APT 2107
IDAHO FALLS ID
83404-7897
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax: 307-333-0470
Mailing address:
  • Phone: 208-403-4364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number163
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: