Provider Demographics
NPI:1780328013
Name:CLARK, LESTER JUNIOR (RN)
Entity type:Individual
Prefix:MR
First Name:LESTER
Middle Name:JUNIOR
Last Name:CLARK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2735 11TH ST W
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-2470
Mailing Address - Country:US
Mailing Address - Phone:701-412-1030
Mailing Address - Fax:
Practice Address - Street 1:2735 11TH ST W
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-2470
Practice Address - Country:US
Practice Address - Phone:701-412-1030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR491493747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant