=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588981575
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLEEN CLARK ANP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2010
-----------------------------------------------------
Last Update Date | 09/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 656 ELMWOOD AVE
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14222-1836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-883-0515
-----------------------------------------------------
Fax | 716-883-8764
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 179 MONTBLEU DR
-----------------------------------------------------
City | GETZVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14068-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-697-2213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 304179
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | F404652-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------