Provider Demographics
NPI:1316304975
Name:CLARK, RACHEL L (MSN, RN, CPNP-PC)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSN, RN, CPNP-PC
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Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:1341 COLORADO AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3917
Mailing Address - Country:US
Mailing Address - Phone:616-405-8556
Mailing Address - Fax:
Practice Address - Street 1:1375 W GREEN ST STE 3
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1708
Practice Address - Country:US
Practice Address - Phone:269-818-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704336827363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics