Provider Demographics
NPI:1407853880
Name:CLARK, NELLDA C (CRNP)
Entity Type:Individual
Prefix:
First Name:NELLDA
Middle Name:C
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 TAYLOR RD
Mailing Address - Street 2:3230
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3588
Mailing Address - Country:US
Mailing Address - Phone:334-265-7075
Mailing Address - Fax:334-261-6113
Practice Address - Street 1:440 TAYLOR RD
Practice Address - Street 2:3300
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3588
Practice Address - Country:US
Practice Address - Phone:334-265-7075
Practice Address - Fax:334-261-6113
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-0473524363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000008426Medicare ID - Type Unspecified
ALS84191Medicare UPIN