Provider Demographics
NPI:1386988194
Name:CLARK, AMY J (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94121-3824
Mailing Address - Country:US
Mailing Address - Phone:415-254-5349
Mailing Address - Fax:
Practice Address - Street 1:731 18TH AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-3824
Practice Address - Country:US
Practice Address - Phone:415-254-5349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA520681163W00000X
CA11270710163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse