Healthcare Provider Details

I. General information

NPI: 1699480202
Provider Name (Legal Business Name): RACHAEL CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 N PERIMETER RD
MALMSTROM AFB MT
59402-6701
US

IV. Provider business mailing address

7300 N PERIMETER RD
MALMSTROM AFB MT
59402-6701
US

V. Phone/Fax

Practice location:
  • Phone: 406-731-2110
  • Fax:
Mailing address:
  • Phone: 406-731-2110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number207866
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: