Provider Demographics
NPI:1699480202
Name:CLARK, RACHAEL
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 N PERIMETER RD
Mailing Address - Street 2:
Mailing Address - City:MALMSTROM AFB
Mailing Address - State:MT
Mailing Address - Zip Code:59402-6701
Mailing Address - Country:US
Mailing Address - Phone:406-731-2110
Mailing Address - Fax:
Practice Address - Street 1:7300 N PERIMETER RD
Practice Address - Street 2:
Practice Address - City:MALMSTROM AFB
Practice Address - State:MT
Practice Address - Zip Code:59402-6701
Practice Address - Country:US
Practice Address - Phone:406-731-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT207866363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner