Provider Demographics
NPI:1518725530
Name:CLARK, MIKALA MARINDA (RN)
Entity Type:Individual
Prefix:
First Name:MIKALA
Middle Name:MARINDA
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 MISSION CT
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:LA
Mailing Address - Zip Code:70094-2565
Mailing Address - Country:US
Mailing Address - Phone:504-256-1502
Mailing Address - Fax:
Practice Address - Street 1:8000 W JUDGE PEREZ DR
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-1668
Practice Address - Country:US
Practice Address - Phone:504-304-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA208951163WC2100X, 163WX1500X, 163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163WC2100XNursing Service ProvidersRegistered NurseContinence Care
No163WX1500XNursing Service ProvidersRegistered NurseOstomy Care