Provider Demographics
NPI:1588981575
Name:CLARK, COLEEN (ANP)
Entity type:Individual
Prefix:
First Name:COLEEN
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 MONTBLEU DR
Mailing Address - Street 2:
Mailing Address - City:GETZVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14068-1330
Mailing Address - Country:US
Mailing Address - Phone:716-697-2213
Mailing Address - Fax:
Practice Address - Street 1:656 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-1836
Practice Address - Country:US
Practice Address - Phone:716-883-0515
Practice Address - Fax:716-883-8764
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304179363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health