Provider Demographics
NPI:1902691173
Name:CLARK, CAROLYN D
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:D
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 1:116 N PAULINE ST # 11-H
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-1005
Mailing Address - Country:US
Mailing Address - Phone:901-523-8990
Mailing Address - Fax:
Practice Address - Street 1:116 N PAULINE ST # 11-H
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-1005
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other