1417253170 NPI number — JULIANNE ALYSSA CLARK ARNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417253170 NPI number — JULIANNE ALYSSA CLARK ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
JULIANNE
Provider Middle Name:
ALYSSA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARTER
Provider Other First Name:
JULIANNE
Provider Other Middle Name:
ALYSSA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417253170
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 849
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHAWNEE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74802-0849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-273-5801
Provider Business Mailing Address Fax Number:
405-878-3814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3315 KETHLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAWNEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74804-9638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-273-5801
Provider Business Practice Location Address Fax Number:
405-878-3814
Provider Enumeration Date:
01/28/2011

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: 363LP0200X , with the licence number:  61442 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 61442 . This is a "OK LICENSE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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