1255144507 NPI number — SELENA NICOLE CHRISTINE CLARK ALC

Table of content: SELENA NICOLE CHRISTINE CLARK ALC (NPI 1255144507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255144507 NPI number — SELENA NICOLE CHRISTINE CLARK ALC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
SELENA
Provider Middle Name:
NICOLE CHRISTINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ALC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255144507
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2114 KILPATRICK LN NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CULLMAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35058-1856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-706-9855
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
623 WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GADSDEN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35901-4136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-673-4346
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2025

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: 101Y00000X , with the licence number:  ACC05193 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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