Provider Demographics
NPI:1396257119
Name:CLARK, MELODIE M
Entity type:Individual
Prefix:MS
First Name:MELODIE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7844 MADISON AVE STE 152
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3540
Mailing Address - Country:US
Mailing Address - Phone:916-344-0249
Mailing Address - Fax:916-344-0739
Practice Address - Street 1:7844 MADISON AVE #152
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-9562
Practice Address - Country:US
Practice Address - Phone:916-344-0249
Practice Address - Fax:916-344-0249
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANONEOtherNONE