Provider Demographics
NPI:1164306809
Name:CLARK, MARIE (NREMT)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:NREMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 W CHINA BASIN RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:ID
Mailing Address - Zip Code:83716-5024
Mailing Address - Country:US
Mailing Address - Phone:206-396-7437
Mailing Address - Fax:
Practice Address - Street 1:97 W PINE ST
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:ID
Practice Address - Zip Code:83716-5032
Practice Address - Country:US
Practice Address - Phone:206-396-7437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8342-4482-1318146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic