Healthcare Provider Details

I. General information

NPI: 1922723634
Provider Name (Legal Business Name): LISA ANN CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

IV. Provider business mailing address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

V. Phone/Fax

Practice location:
  • Phone: 734-925-6687
  • Fax:
Mailing address:
  • Phone: 734-925-6687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4704918286
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: