Basic Information
| Provider Information | |||||||||
| NPI: | 1114029238 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC, APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK-BEAN | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-BC, APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | #4 HOSPITAL DRIVE | ||||||||
| Address2: | ST. VINCENT MORRILTON HOSPITAL | ||||||||
| City: | MORRILTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721104510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019772300 | ||||||||
| FaxNumber: | 7708745483 | ||||||||
| Practice Location | |||||||||
| Address1: | #4 HOSPITAL DRIVE | ||||||||
| Address2: | ST. VINCENT MORRILTON HOSPITAL | ||||||||
| City: | MORRILTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721104510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019772300 | ||||||||
| FaxNumber: | 5019772341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 10/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A001810 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 117992003 | 05 | AR | MEDICAID |