Provider Demographics
NPI:1548246747
Name:CLARK, LYREVA J (RNFNP-C)
Entity type:Individual
Prefix:
First Name:LYREVA
Middle Name:J
Last Name:CLARK
Suffix:
Gender:F
Credentials:RNFNP-C
Other - Prefix:
Other - First Name:LYREVA
Other - Middle Name:J
Other - Last Name:NOLLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RNFNP-C
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-0551
Mailing Address - Country:US
Mailing Address - Phone:573-588-4134
Mailing Address - Fax:573-588-4876
Practice Address - Street 1:6500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6890
Practice Address - Country:US
Practice Address - Phone:573-629-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003005715363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429238306Medicaid
MOQ01943Medicare UPIN
MO823801740Medicare PIN
MO429238306Medicaid