Provider Demographics
NPI:1588718852
Name:CLARK, CATHY (CNM)
Entity type:Individual
Prefix:MRS
First Name:CATHY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 CARTHAGE STREET
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330
Mailing Address - Country:US
Mailing Address - Phone:919-775-2304
Mailing Address - Fax:919-775-4050
Practice Address - Street 1:1140 CARTHAGE STREET
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330
Practice Address - Country:US
Practice Address - Phone:919-775-2304
Practice Address - Fax:919-775-4050
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC081217367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC081217OtherRN LICENSE
NCNC230OtherNC APPROVAL TO PRACTICE