Provider Demographics
NPI:1376742841
Name:CLARK, LISA M (LMP)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7011
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98417-0011
Mailing Address - Country:US
Mailing Address - Phone:253-820-1303
Mailing Address - Fax:
Practice Address - Street 1:4308 N 26TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98407-5211
Practice Address - Country:US
Practice Address - Phone:253-820-1303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024438174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist