Provider Demographics
NPI:1124004700
Name:CLARK, REBECCA ELIZABETH (MSN, RN, APRN-BC)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:MSN, RN, APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-5252
Mailing Address - Country:US
Mailing Address - Phone:931-381-5157
Mailing Address - Fax:
Practice Address - Street 1:1811 STATE ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2205
Practice Address - Country:US
Practice Address - Phone:615-329-4357
Practice Address - Fax:615-329-3102
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN77471363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00869Medicare UPIN