Active NPI
Judith CR Clark, NP
- Nurse Practitioner
- Farmington Hills, MI
National Provider Identifier
1780682138
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Nurse Practitioner
- License
- 4704171391
- Practice address
- 32605 W 12 Mile Rd Ste 195
Farmington Hills, MI 48334-3390 - Phone
- (313) 306-2023
- NPI assigned
- Jul 11, 2005
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nurse Practitioner | 363L00000X | 4704171391 | MI | Primary |
Addresses
Primary practice location
32605 W 12 Mile Rd Ste 195
Farmington Hills, MI 48334-3390
Mailing address
3621 S State St
700 KMS Place
Ann Arbor, MI 48108
Phone (734) 936-2047
Other practice location 1
375 Briarwood Cir
Ann Arbor, MI 48108-1605
Phone (734) 998-7207
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| P00365326 | Other | MI | MEDICARE-RAILROAD |
| 5008707110 | Other | MI | BCBSM |
| 4643072 | Medicaid | MI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4704171391 | MI | MD | Nurse Practitioner |
Interoperability endpoints
- juclark@landmarkhealth-direct.org
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1121040000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1655683200000",
"number": "1780682138",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3621 S STATE ST",
"address_2": "700 KMS PLACE",
"city": "ANN ARBOR",
"state": "MI",
"postal_code": "48108",
"telephone_number": "734-936-2047"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "32605 W 12 MILE RD STE 195",
"city": "FARMINGTON HILLS",
"state": "MI",
"postal_code": "483343390",
"telephone_number": "313-306-2023"
}
],
"practiceLocations": [
{
"address_1": "375 Briarwood Cir",
"address_purpose": "LOCATION",
"city": "Ann Arbor",
"state": "MI",
"postal_code": "481081605",
"country_code": "US",
"telephone_number": "734-998-7207",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "CLARK",
"first_name": "JUDITH",
"middle_name": "CR",
"credential": "NP",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2005-07-11",
"last_updated": "2022-06-20",
"certification_date": "2022-06-20",
"status": "A"
},
"taxonomies": [
{
"code": "363L00000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner",
"state": "MI",
"license": "4704171391",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE-RAILROAD",
"identifier": "P00365326",
"state": "MI"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBSM",
"identifier": "5008707110",
"state": "MI"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "4643072",
"state": "MI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Farmington Hills, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.