Provider Demographics
NPI:1396963666
Name:CLARK, ROBERT (LPN)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 171
Mailing Address - Street 2:
Mailing Address - City:ISTACHATTA
Mailing Address - State:FL
Mailing Address - Zip Code:34636-0171
Mailing Address - Country:US
Mailing Address - Phone:352-650-3825
Mailing Address - Fax:352-799-5200
Practice Address - Street 1:26347 LAKE LINDSEY RD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-4304
Practice Address - Country:US
Practice Address - Phone:352-650-3825
Practice Address - Fax:352-799-5200
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN1295281164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPN1295281OtherLPN