Provider Demographics
NPI:1699236794
Name:CLARK, KARRAH (APRN)
Entity type:Individual
Prefix:
First Name:KARRAH
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1154 SOUTHFIELD CUTOFF
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-3451
Mailing Address - Country:US
Mailing Address - Phone:870-562-3392
Mailing Address - Fax:
Practice Address - Street 1:804 N BEECH ST
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-3809
Practice Address - Country:US
Practice Address - Phone:318-574-1453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA204406363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics