Provider Demographics
NPI:1104970151
Name:CLARK, SHARON ROSE (RNC,CNM)
Entity type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:ROSE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RNC,CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032-9656
Mailing Address - Country:US
Mailing Address - Phone:269-467-7063
Mailing Address - Fax:
Practice Address - Street 1:600 S LAKEVIEW ST
Practice Address - Street 2:STE. 202
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-2371
Practice Address - Country:US
Practice Address - Phone:269-659-0174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704092855163WM0102X, 176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
Not Answered176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4565978Medicaid