Provider Demographics
NPI:1841682044
Name:CLARK, SAMANTHA (NP-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 RIVER OAKS DR STE B103
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7602
Mailing Address - Country:US
Mailing Address - Phone:601-366-1011
Mailing Address - Fax:601-932-6111
Practice Address - Street 1:1080 RIVER OAKS DR STE B103
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-7602
Practice Address - Country:US
Practice Address - Phone:601-366-1011
Practice Address - Fax:601-932-6111
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR874456363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily