Provider Demographics
NPI:1699546622
Name:CLARK, CAMILLE (RN)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
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:PO BOX 3050
Mailing Address - Street 2:
Mailing Address - City:THATCHER
Mailing Address - State:AZ
Mailing Address - Zip Code:85552-3050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1491 W THATCHER BLVD STE 104
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-3431
Practice Address - Country:US
Practice Address - Phone:928-428-0734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ242065163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health