Provider Demographics
NPI:1467821629
Name:CLARK, COURTNEY (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LEIGH
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1717 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8991
Mailing Address - Country:US
Mailing Address - Phone:337-494-4900
Mailing Address - Fax:337-494-4963
Practice Address - Street 1:1717 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8991
Practice Address - Country:US
Practice Address - Phone:337-494-4900
Practice Address - Fax:337-494-4963
Is Sole Proprietor?:No
Enumeration Date:2015-09-17
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08371363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily