Provider Demographics
NPI:1720377278
Name:CLARK, LORETTA A (LMP)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 E HEROY AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-1535
Mailing Address - Country:US
Mailing Address - Phone:509-413-7070
Mailing Address - Fax:509-489-4674
Practice Address - Street 1:216 W PACIFIC AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-3661
Practice Address - Country:US
Practice Address - Phone:509-413-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60097219305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization