Basic Information
| Provider Information | |||||||||
| NPI: | 1588981575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | COLEEN | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 179 MONTBLEU DR | ||||||||
| Address2: | |||||||||
| City: | GETZVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140681330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166972213 | ||||||||
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| Practice Location | |||||||||
| Address1: | 656 ELMWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142221836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168830515 | ||||||||
| FaxNumber: | 7168838764 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2010 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 304179 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.