Provider Demographics
NPI:1700147436
Name:CLARK, SHANNON (BSE)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:BSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GENERAL STREET
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501
Mailing Address - Country:US
Mailing Address - Phone:870-793-3200
Mailing Address - Fax:
Practice Address - Street 1:200 GENERAL ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-9407
Practice Address - Country:US
Practice Address - Phone:870-793-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist