Stephanie Clark, NP

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

NP-1100A Issued in ID

Practice address

1951 Bench Road
Ste a
Pocatello, ID 83201-2073

Phone

(208) 549-7385

Fax

(208) 216-6761

NPI assigned

Sep 8, 2011

Last updated

Sep 21, 2023By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Jan 1, 2025 through Jan 1, 2027

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Lily Pad Wellness, LLC

  • Nurse Practitioner
  • Pocatello, ID
  • NPI 1275214660
  NPD Authorized official
• MVH PMHS LLC

  • Mental Health Counselor
  • Pocatello, ID
  • NPI 1649704248
  NPD (past)
• Safe Haven Health Care LLC

  dba Safe Haven Hospital of Pocatello

  • Psychiatric Hospital
  • Pocatello, ID
  • NPI 1619208709
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1315440000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1695254400000",
    "number": "1912288572",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1951 BENCH ROAD",
            "address_2": "STE A",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832012073",
            "telephone_number": "208-549-7385",
            "fax_number": "208-216-6761"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1951 BENCH ROAD",
            "address_2": "STE A",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832012073",
            "telephone_number": "208-549-7385",
            "fax_number": "208-216-6761"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLARK",
        "first_name": "STEPHANIE",
        "credential": "NP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2011-09-08",
        "last_updated": "2023-09-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "ID",
            "license": "NP-1100A",
            "primary": true
        },
        {
            "code": "163W00000X",
            "taxonomy_group": "",
            "desc": "Registered Nurse",
            "state": "ID",
            "license": "N-35468",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Chad Alan Clark
• Dillon Clark
• Jeremy Clark
• Sarah Michelle Clark, LPC
• Sharla Clark, D.O.
• Becky Lynn Clarke, MRC
• Emery Eugene Clayson, PSYD
• Kaitlin Michelle Clayson, M.COUN, LCPC
• Sierra Lucette Clayson
• Tasman Cleaver

• Nurse Practitioner in Pocatello, ID
• Providers in Pocatello, ID by specialty
• Nurse Practitioner in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 21, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.