| Doctor Name: | MARY CLARK |
| NPI Number: | 1285043372 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 200540995RN |
| Business Practice Address: | 8495 Crater Lake Hwy White City, OR - 975033011 |
| Business Phone Number: | 5418262111 |
| Business Fax Number: | 5418307481 |
| Mailing Address: | 8495 Crater Lake Hwy, WHITE CITY |
| State: | OR |
| Postal Code: | 975033011 |
| Phone Number: | 5418262111 |
| Fax Number: | 5418307481 |
| NPI Enumeration Date: | 08/04/2014 |
| NPI Last Update Date: | 08/04/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 163WC0400X |
| License Number: | 200540995RN |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | OR |
| Taxonomy Type: | Nursing Service Providers |
| Taxonomy Classification: | Registered Nurse |
| Taxonomy Specialization: | Case Management |
| Taxonomy Definition: | |