Provider Demographics
NPI:1821220575
Name:CLARK, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
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 1:283 WINSLOW WAY
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:GA
Mailing Address - Zip Code:30620-3248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:283 WINSLOW WAY
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:GA
Practice Address - Zip Code:30620-3248
Practice Address - Country:US
Practice Address - Phone:678-361-1117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA37433174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist