Provider Demographics
NPI:1114762689
Name:CLARK, RONNIE MASHETTE (CRNP)
Entity type:Individual
Prefix:MISS
First Name:RONNIE
Middle Name:MASHETTE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 171
Mailing Address - Street 2:
Mailing Address - City:POCOMOKE CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21851-0171
Mailing Address - Country:US
Mailing Address - Phone:443-497-8818
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 171
Practice Address - Street 2:
Practice Address - City:POCOMOKE CITY
Practice Address - State:MD
Practice Address - Zip Code:21851-0171
Practice Address - Country:US
Practice Address - Phone:443-497-8818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR203521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine