Provider Demographics
NPI:1548398506
Name:CLARK, MELISSA DARLENE (LPN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DARLENE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 DARRELL RYE RD
Mailing Address - Street 2:
Mailing Address - City:ERIN
Mailing Address - State:TN
Mailing Address - Zip Code:37061-6933
Mailing Address - Country:US
Mailing Address - Phone:931-289-5254
Mailing Address - Fax:
Practice Address - Street 1:105 WAVERLY PLZ
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185-1531
Practice Address - Country:US
Practice Address - Phone:931-296-4356
Practice Address - Fax:931-296-4529
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000068909164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse