Provider Demographics
NPI:1598163453
Name:CLARK, CRAIG Y (RN)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:Y
Last Name:CLARK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 SPURWINK RD
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-8607
Mailing Address - Country:US
Mailing Address - Phone:207-776-2023
Mailing Address - Fax:
Practice Address - Street 1:149 SPURWINK RD
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8607
Practice Address - Country:US
Practice Address - Phone:207-776-2023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN49820163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics