Provider Demographics
NPI:1548893506
Name:CLARK, THERESA ANN (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69014 TAMARACK RD
Mailing Address - Street 2:
Mailing Address - City:WALKERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46574-9735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-8985
Practice Address - Country:US
Practice Address - Phone:574-825-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28108427A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily