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General NPI Number Information
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NPI Number | 1972921468
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Entity Type | Individual
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Provider Name | VICKI MARIE CLARK RN
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Gender | Female
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Dates
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Enumeration Date | 04/01/2014
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Last Update Date | 04/01/2014
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Provider Practice Location Address
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Address Line | 6071 W OUTER DR
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City | DETROIT
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State | MI
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Zip | 48235-2624
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Country | US
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Telephone | 313-966-6050
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Fax |
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Provider Business Mailing Address
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Address Line | 4680 HUNTERS CIR W
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City | CANTON
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State | MI
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Zip | 48188-2377
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Country | US
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Telephone | 313-920-8812
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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 | 163WC0200X
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Taxonomy Name | Critical Care Medicine Registered Nurse
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License Number | 4704212789
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License Number State | MI
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