Healthcare Provider Details

I. General information

NPI: 1841908894
Provider Name (Legal Business Name): SAMANTHA LEIGH CLARK C-PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4904 RIVER RD N
KEIZER OR
97303-4540
US

IV. Provider business mailing address

4904 RIVER RD N
KEIZER OR
97303-4540
US

V. Phone/Fax

Practice location:
  • Phone: 503-390-2434
  • Fax:
Mailing address:
  • Phone: 503-390-2434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number10047719
License Number StateOR

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: