Provider Demographics
NPI:1679710479
Name:CLARK, REGINA K (CPNP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:K
Last Name:CLARK
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:K
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1122 NE 13TH ST
Mailing Address - Street 2:ORI 236
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 N PHILLIPS AVE
Practice Address - Street 2:SUITE 9500
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4600
Practice Address - Country:US
Practice Address - Phone:405-271-6549
Practice Address - Fax:405-271-7866
Is Sole Proprietor?:No
Enumeration Date:2009-01-15
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0070771363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner