Provider Demographics
NPI:1336227875
Name:CLARK, LAURA ANN (APN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS WAY # 653
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:501-364-2963
Practice Address - Street 1:1 CHILDRENS WAY # 653
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202
Practice Address - Country:US
Practice Address - Phone:501-364-1100
Practice Address - Fax:501-364-2963
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01827363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
A01827OtherTRICARE
A01827OtherTRICARE