Provider Demographics
NPI:1285704544
Name:CLARK, AMY WILSON (NP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:WILSON
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:1718 E 4TH ST
Practice Address - Street 2:SUITE 601
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3261
Practice Address - Country:US
Practice Address - Phone:704-384-1246
Practice Address - Fax:704-384-1249
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC950019363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2592149AMedicare PIN
NCS86914Medicare UPIN