Provider Demographics
NPI:1184196081
Name:CLARK, LAURA ANN (FAMILY NURSE PRACTIT)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:FAMILY NURSE PRACTIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 SWEETBAY DR
Mailing Address - Street 2:
Mailing Address - City:MAYLENE
Mailing Address - State:AL
Mailing Address - Zip Code:35114-4942
Mailing Address - Country:US
Mailing Address - Phone:205-568-9827
Mailing Address - Fax:205-278-7660
Practice Address - Street 1:120 COLONIAL PROMENADE PKWY
Practice Address - Street 2:
Practice Address - City:ALABASTER
Practice Address - State:AL
Practice Address - Zip Code:35007-3155
Practice Address - Country:US
Practice Address - Phone:205-421-2088
Practice Address - Fax:205-278-7660
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-120961363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner