Provider Demographics
NPI:1417663733
Name:CLARK, LATOYA S (LPN)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11445 REIGER RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-4556
Mailing Address - Country:US
Mailing Address - Phone:225-932-9867
Mailing Address - Fax:
Practice Address - Street 1:11445 REIGER RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-4556
Practice Address - Country:US
Practice Address - Phone:225-932-9867
Practice Address - Fax:225-932-9870
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20130120164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA05Medicaid