Provider Demographics
NPI:1891987343
Name:CLARK, REBECCA S (FNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 E BERT KOUN LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-798-4539
Mailing Address - Fax:318-798-4601
Practice Address - Street 1:10600 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-5105
Practice Address - Country:US
Practice Address - Phone:318-798-4616
Practice Address - Fax:318-798-4619
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1362484Medicaid
LA5CW58Medicare PIN
LA1362484Medicaid