Provider Demographics
NPI:1386142685
Name:CLARK, RACHEL NACOLE
Entity type:Individual
Prefix:MRS
First Name:RACHEL
Middle Name:NACOLE
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 1:13005 ARLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURG
Mailing Address - State:MO
Mailing Address - Zip Code:65550-9063
Mailing Address - Country:US
Mailing Address - Phone:573-465-2268
Mailing Address - Fax:
Practice Address - Street 1:1000 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2905
Practice Address - Country:US
Practice Address - Phone:573-458-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018001797363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical