Provider Demographics
NPI:1477669513
Name:CLARK, REBECCA SUE (CRNA, MS, BSN)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:SUE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA, MS, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 ASHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:IA
Mailing Address - Zip Code:50036-7190
Mailing Address - Country:US
Mailing Address - Phone:515-370-1054
Mailing Address - Fax:
Practice Address - Street 1:1015 UNION ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:IA
Practice Address - Zip Code:50036-4821
Practice Address - Country:US
Practice Address - Phone:515-370-1054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2009-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA113814163W00000X
IA074139367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse