Provider Demographics
NPI:1114918158
Name:CLARK, EDNA MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:MICHELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 SLADE ST
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-3941
Mailing Address - Country:US
Mailing Address - Phone:912-368-2107
Mailing Address - Fax:
Practice Address - Street 1:635 SLADE ST
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3941
Practice Address - Country:US
Practice Address - Phone:912-368-2107
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN047051164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse