Provider Demographics
NPI:1497116644
Name:CLARK, CONSTANCE
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2792 S 2ND ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-7020
Mailing Address - Country:US
Mailing Address - Phone:501-941-3500
Mailing Address - Fax:
Practice Address - Street 1:2792 S 2ND ST
Practice Address - Street 2:SUITE B
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-7020
Practice Address - Country:US
Practice Address - Phone:501-941-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR097900163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse