Provider Demographics
NPI:1255844023
Name:CLARK, LETRICIA LENISE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LETRICIA
Middle Name:LENISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28800 RYAN RD STE 320
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-4272
Mailing Address - Country:US
Mailing Address - Phone:586-582-0500
Mailing Address - Fax:586-834-2231
Practice Address - Street 1:28800 RYAN RD STE 320
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4272
Practice Address - Country:US
Practice Address - Phone:586-582-0500
Practice Address - Fax:586-834-2231
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704261814363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty