Individual
ELLICE CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
4001 W MCNICHOLS RD, DETROIT, MI 48221-3038
(313) 993-1245
Mailing address
13032 WOODRIDGE CIR, PLYMOUTH, MI 48170-3892
(989) 295-4067
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
4704345479
MI
367500000X
Certified Registered Nurse Anesthetist
Primary
4704345479
MI
Other
Enumeration date
01/09/2023
Last updated
11/21/2024
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