Healthcare Provider Details

I. General information

NPI: 1942372966
Provider Name (Legal Business Name): TERRI LEE CLARK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 N RYNDERS ST
GRAND CHUTE WI
54914-1614
US

IV. Provider business mailing address

1505 N RYNDERS ST
GRAND CHUTE WI
54914-1614
US

V. Phone/Fax

Practice location:
  • Phone: 920-993-8445
  • Fax: 920-993-8445
Mailing address:
  • Phone: 920-993-8445
  • Fax: 920-993-8445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: