Provider Demographics
NPI:1407490246
Name:CLARK, LAURIE BETH (CNP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:BETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17009 E CHEYENNE DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64056-1516
Mailing Address - Country:US
Mailing Address - Phone:816-337-2192
Mailing Address - Fax:
Practice Address - Street 1:17009 E CHEYENNE DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64056
Practice Address - Country:US
Practice Address - Phone:816-337-2192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019042366363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care