Provider Demographics
NPI:1316737703
Name:CLARK, AMANDA JILL
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JILL
Last Name:CLARK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 BRIAR AVE
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2864
Mailing Address - Country:US
Mailing Address - Phone:951-581-0710
Mailing Address - Fax:
Practice Address - Street 1:1800 NOVELL PL
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-6171
Practice Address - Country:US
Practice Address - Phone:951-581-0710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program