1548297708 NPI number — MS. PAULETTE JEAN CLARK CRNA

Table of content: (NPI 1922022607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548297708 NPI number — MS. PAULETTE JEAN CLARK CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
PAULETTE
Provider Middle Name:
JEAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
PAULETTE
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1548297708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBION
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68620-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-395-6897
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2439 260TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBION
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68620-5584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-395-6897
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2006

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: 163W00000X , with the licence number:  26343 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 100340 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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