Provider Demographics
NPI:1659836054
Name:CLARK, ANTOINETTE YVETTE
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:YVETTE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 W ERCOUPE DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-5515
Mailing Address - Country:US
Mailing Address - Phone:228-546-1645
Mailing Address - Fax:
Practice Address - Street 1:227 W ERCOUPE DR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-5515
Practice Address - Country:US
Practice Address - Phone:228-546-1645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-10
Last Update Date:2019-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty