Provider Demographics
NPI:1972645828
Name:CLARK, LORA JOHNSON
Entity Type:Individual
Prefix:MRS
First Name:LORA
Middle Name:JOHNSON
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 1:1136 AUSTIN CIR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-2900
Mailing Address - Country:US
Mailing Address - Phone:931-762-9429
Mailing Address - Fax:
Practice Address - Street 1:2366 SPRINGER RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-4459
Practice Address - Country:US
Practice Address - Phone:931-766-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA0000002621225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant