Provider Demographics
NPI:1588616858
Name:CLARK, LEAH DIANE (ARNP)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:DIANE
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14715 TALL TREE DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-3246
Mailing Address - Country:US
Mailing Address - Phone:813-877-2200
Mailing Address - Fax:813-984-2495
Practice Address - Street 1:3010 W AZEELE ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3139
Practice Address - Country:US
Practice Address - Phone:813-877-2200
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3071812363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner