Provider Demographics
NPI:1710562129
Name:CLARK, URSULA LORI
Entity Type:Individual
Prefix:
First Name:URSULA
Middle Name:LORI
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 1:4700 ROLLING PINE DR APT D25
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-4935
Mailing Address - Country:US
Mailing Address - Phone:305-877-6401
Mailing Address - Fax:
Practice Address - Street 1:4700 ROLLING PINE DR APT D25
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:GA
Practice Address - Zip Code:31636-4935
Practice Address - Country:US
Practice Address - Phone:305-877-6401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor