Provider Demographics
NPI:1114331543
Name:CLARK, REBECCA THERESA (RN)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:THERESA
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 LASALETTE AVE
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70663-5124
Mailing Address - Country:US
Mailing Address - Phone:337-304-7985
Mailing Address - Fax:
Practice Address - Street 1:3236 KIRKMAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8640
Practice Address - Country:US
Practice Address - Phone:337-478-6020
Practice Address - Fax:337-475-4820
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN088489163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health