1114029238 NPI number — LAURA KAY CLARK FNP-BC, APRN

Table of content: LAURA KAY CLARK FNP-BC, APRN (NPI 1114029238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114029238 NPI number — LAURA KAY CLARK FNP-BC, APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
LAURA
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC, APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK-BEAN
Provider Other First Name:
LAURA
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-BC, APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114029238
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
#4 HOSPITAL DRIVE
Provider Second Line Business Mailing Address:
ST. VINCENT MORRILTON HOSPITAL
Provider Business Mailing Address City Name:
MORRILTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72110-4510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-977-2300
Provider Business Mailing Address Fax Number:
770-874-5483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
#4 HOSPITAL DRIVE
Provider Second Line Business Practice Location Address:
ST. VINCENT MORRILTON HOSPITAL
Provider Business Practice Location Address City Name:
MORRILTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72110-4510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-977-2300
Provider Business Practice Location Address Fax Number:
501-977-2341
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  A001810 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 117992003 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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