Provider Demographics
NPI:1518362227
Name:DECLERK, AMY (APRN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DECLERK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2018 HWY 67 N
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455-9438
Mailing Address - Country:US
Mailing Address - Phone:870-202-1048
Mailing Address - Fax:
Practice Address - Street 1:2018 HIGHWAY 67 S
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-4169
Practice Address - Country:US
Practice Address - Phone:870-202-1048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARF1014430363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care