MEDICARE: MARYANNE C CLARK PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP11153	AZ
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP11154	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982685954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYANNE C CLARK PMHNP

Provider Business Mailing Address
First Line	:	202 E EARLL DR STE 200
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2647
Country	:	US
Telephone Number	:	602-865-0008
Fax Number	:

Provider Business Practice Location Address
First Line	:	2715 N 3RD ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-1106
Country	:	US
Telephone Number	:	602-264-4331
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	02/19/2019

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