Provider Demographics
NPI:1386070886
Name:CLARK, TENNIE I (MSA)
Entity type:Individual
Prefix:
First Name:TENNIE
Middle Name:I
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 W DURANT AVE
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-2243
Mailing Address - Country:US
Mailing Address - Phone:918-917-3532
Mailing Address - Fax:918-465-0300
Practice Address - Street 1:805 W DURANT AVE
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-2243
Practice Address - Country:US
Practice Address - Phone:918-917-3532
Practice Address - Fax:918-465-0300
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator