Provider Demographics
NPI:1154767564
Name:CLARK, AMBER LEE (LMT)
Entity type:Individual
Prefix:MS
First Name:AMBER
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 NW ARIZONA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3298
Mailing Address - Country:US
Mailing Address - Phone:541-678-4212
Mailing Address - Fax:
Practice Address - Street 1:701 NW ARIZONA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3298
Practice Address - Country:US
Practice Address - Phone:541-678-4212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10629172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker