Individual
CHARLENE CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
120 DESERT SAGE WAY, MOUNTAIN HOME, ID 83647-1038
(208) 587-3988
(208) 587-3324
Mailing address
1205 TETON AVE, CALDWELL, ID 83605-2553
(901) 500-5766
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
19070
TN
363LF0000X
Family Nurse Practitioner
73782
ID
363LF0000X
Family Nurse Practitioner
Primary
AP61098520
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
19070
APN LICENSE
TN
Enumeration date
09/15/2014
Last updated
01/08/2025
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