Provider Demographics
NPI:1417253170
Name:CLARK, JULIANNE ALYSSA (ARNP)
Entity type:Individual
Prefix:
First Name:JULIANNE
Middle Name:ALYSSA
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JULIANNE
Other - Middle Name:ALYSSA
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74802-0849
Mailing Address - Country:US
Mailing Address - Phone:405-273-5801
Mailing Address - Fax:405-878-3814
Practice Address - Street 1:3315 KETHLEY RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-9638
Practice Address - Country:US
Practice Address - Phone:405-273-5801
Practice Address - Fax:405-878-3814
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK61442363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK61442OtherOK LICENSE