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General NPI Number Information
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NPI Number | 1881126894
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Entity Type | Individual
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Provider Name | MARY ANN CLARK
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Gender | Female
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Dates
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Enumeration Date | 03/29/2017
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Last Update Date | 03/29/2017
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Provider Practice Location Address
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Address Line | 2240 E WINROW AVE
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City | FORT HUACHUCA
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State | AZ
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Zip | 85613
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Country | US
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Telephone | 520-533-3533
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Fax |
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Provider Business Mailing Address
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Address Line | 4571 PASEO BRAZOS
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City | SIERRA VISTA
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State | AZ
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Zip | 85635-2376
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Country | US
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Telephone |
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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 | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 1-125268
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License Number State | AL
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