Provider Demographics
NPI:1336852508
Name:CLARK, COURTNEY LAYNE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LAYNE
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 1:9210 NEBER RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-8814
Mailing Address - Country:US
Mailing Address - Phone:618-771-2524
Mailing Address - Fax:
Practice Address - Street 1:9210 NEBER RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-8814
Practice Address - Country:US
Practice Address - Phone:618-771-2524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041455068163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse