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General NPI Number Information
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NPI Number | 1457498214
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Entity Type | Individual
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Provider Name | MAYA CLARK NP
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Gender | Female
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 13400 W OUTER DR
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City | DETROIT
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State | MI
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Zip | 48239-1309
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Country | US
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Telephone | 313-592-5216
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Fax | 313-592-5012
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Provider Business Mailing Address
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Address Line | 13924 BURNING TREE LN
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City | PLYMOUTH
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State | MI
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Zip | 48170-2699
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Country | US
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Telephone | 734-667-5282
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 4704173166
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License Number State | MI
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