Provider Demographics
NPI:1225861016
Name:CLARK, JEANETTE CRISTINE (RN)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:CRISTINE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 SHORE RD APT 5C
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4735
Mailing Address - Country:US
Mailing Address - Phone:732-887-7093
Mailing Address - Fax:
Practice Address - Street 1:24 ROBERTS ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-5042
Practice Address - Country:US
Practice Address - Phone:516-293-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY861777-01163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice