Provider Demographics
NPI:1154523652
Name:CLARK, CARMEN ELENA (IBCLC, RLC)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:ELENA
Last Name:CLARK
Suffix:
Gender:F
Credentials:IBCLC, RLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3021
Mailing Address - Country:US
Mailing Address - Phone:201-837-7646
Mailing Address - Fax:201-353-7936
Practice Address - Street 1:324 EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-3021
Practice Address - Country:US
Practice Address - Phone:201-837-7646
Practice Address - Fax:201-353-7936
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ105-21643OtherIBCLC NUMBER