Provider Demographics
NPI:1114631728
Name:CLARK, LAURA CAITLIN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:CAITLIN
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 1:417 N NORTHWEST HWY APT 2F
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3258
Mailing Address - Country:US
Mailing Address - Phone:337-207-4301
Mailing Address - Fax:
Practice Address - Street 1:417 N NORTHWEST HWY APT 2F
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3258
Practice Address - Country:US
Practice Address - Phone:337-207-4301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant