Provider Demographics
NPI:1720245673
Name:CLARK, SAMUEL (FNP)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 LAUDHOLM FARM RD
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:ME
Mailing Address - Zip Code:04090-4707
Mailing Address - Country:US
Mailing Address - Phone:617-320-5256
Mailing Address - Fax:
Practice Address - Street 1:112 SANFORD RD
Practice Address - Street 2:
Practice Address - City:WELLS
Practice Address - State:ME
Practice Address - Zip Code:04090-5533
Practice Address - Country:US
Practice Address - Phone:207-646-5211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP241398363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily