Provider Demographics
NPI:1710940333
Name:CLARK, LOUANN (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:LOUANN
Middle Name:
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:PO BOX 232
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33526
Mailing Address - Country:US
Mailing Address - Phone:352-518-2000
Mailing Address - Fax:352-567-5193
Practice Address - Street 1:14027 5TH ST
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-4302
Practice Address - Country:US
Practice Address - Phone:352-518-2000
Practice Address - Fax:352-567-0218
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3198092363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3021360000Medicaid