Provider Demographics
NPI:1215519814
Name:CLARK, DESA MARIAH (APRN)
Entity type:Individual
Prefix:
First Name:DESA
Middle Name:MARIAH
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:DESA
Other - Middle Name:MARIAH
Other - Last Name:ELDRIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:605 E THOMSEN ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-9235
Mailing Address - Country:US
Mailing Address - Phone:402-317-0797
Mailing Address - Fax:
Practice Address - Street 1:2560 N HEALTHY WAY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2315
Practice Address - Country:US
Practice Address - Phone:402-941-7245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE64709163W00000X
NE113657363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse