Provider Demographics
NPI:1215491048
Name:CLARK, LEE ANN
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 N BEARD AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-6105
Mailing Address - Country:US
Mailing Address - Phone:918-696-1545
Mailing Address - Fax:
Practice Address - Street 1:326 W 11TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-6710
Practice Address - Country:US
Practice Address - Phone:918-696-1545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator