Provider Demographics
NPI:1568061950
Name:CLARK, KECIA (FNP)
Entity Type:Individual
Prefix:
First Name:KECIA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6544 OAK GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-5806
Mailing Address - Country:US
Mailing Address - Phone:337-368-8485
Mailing Address - Fax:
Practice Address - Street 1:1818 S SHERWOOD FOREST BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8321
Practice Address - Country:US
Practice Address - Phone:337-368-8485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA215920363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily