Provider Demographics
NPI:1255910386
Name:CLARK, LEA L
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:L
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 1:834 N SEMINARY ST
Mailing Address - Street 2:STE 201
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2898
Mailing Address - Country:US
Mailing Address - Phone:309-343-7195
Mailing Address - Fax:
Practice Address - Street 1:717 KNOX COUNTY HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:YATES CITY
Practice Address - State:IL
Practice Address - Zip Code:61572
Practice Address - Country:US
Practice Address - Phone:309-264-2457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021458363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner