Healthcare Provider Details

I. General information

NPI: 1417483553
Provider Name (Legal Business Name): MACEY CLARK PNP-C, AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 SUNSET DR SUITE E
LA GRANDE OR
97850-1200
US

IV. Provider business mailing address

PO BOX 3290
LA GRANDE OR
97850-7290
US

V. Phone/Fax

Practice location:
  • Phone: 541-962-5600
  • Fax:
Mailing address:
  • Phone: 541-963-1967
  • Fax: 541-963-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number201704371NP-PP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201704371NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: