Provider Demographics
NPI:1063563310
Name:CLARK, BONNIE L (WHNP-BC)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:MRS
Other - First Name:BONNIE
Other - Middle Name:LC
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 SILVER RDG
Mailing Address - Street 2:
Mailing Address - City:VEAZIE
Mailing Address - State:ME
Mailing Address - Zip Code:04401-7086
Mailing Address - Country:US
Mailing Address - Phone:207-942-0824
Mailing Address - Fax:207-942-0824
Practice Address - Street 1:5 SILVER RDG
Practice Address - Street 2:
Practice Address - City:VEAZIE
Practice Address - State:ME
Practice Address - Zip Code:04401-7086
Practice Address - Country:US
Practice Address - Phone:207-942-0824
Practice Address - Fax:207-942-0824
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81695363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MECNP81695OtherMAINE STATE BOARD OF NURSING
MERN18038OtherMAINE STATE BOARD OF NURSING