Healthcare Provider Details

I. General information

NPI: 1710969498
Provider Name (Legal Business Name): JOAN MARIE CLARK ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 CLAYTON RD STE 302
SAINT LOUIS MO
63117-1850
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-1019
US

V. Phone/Fax

Practice location:
  • Phone: 314-645-3370
  • Fax: 314-645-0576
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2816742621
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: