Provider Demographics
NPI:1043613649
Name:CLARK, DANIEL (NURSE PRACITIONER)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:NURSE PRACITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9230 AUTUMNGLO DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-1608
Mailing Address - Country:US
Mailing Address - Phone:248-330-5808
Mailing Address - Fax:
Practice Address - Street 1:401 S BALLENGER HWY
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3638
Practice Address - Country:US
Practice Address - Phone:810-342-5700
Practice Address - Fax:810-342-5504
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-27
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704269853363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily