Provider Demographics
NPI:1558478933
Name:CLARK, RICKETTA (NP)
Entity Type:Individual
Prefix:MRS
First Name:RICKETTA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:RICKETTA
Other - Middle Name:L
Other - Last Name:HARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:880 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3409
Mailing Address - Country:US
Mailing Address - Phone:901-490-7929
Mailing Address - Fax:
Practice Address - Street 1:880 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3409
Practice Address - Country:US
Practice Address - Phone:901-490-7929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7029363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3905917Medicaid
TN3905917Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
TNP02447Medicare UPIN