Provider Demographics
NPI:1689066367
Name:CLARK, SHELLEY B (LPTA)
Entity Type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:B
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6520 SUNSCOPE DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-8690
Mailing Address - Country:US
Mailing Address - Phone:228-875-1177
Mailing Address - Fax:228-872-4009
Practice Address - Street 1:6520 SUNSCOPE DR
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-8690
Practice Address - Country:US
Practice Address - Phone:228-875-1177
Practice Address - Fax:228-872-4009
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA4100314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility