Healthcare Provider Details

I. General information

NPI: 1023927720
Provider Name (Legal Business Name): CHELA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 BANNERWOOD DR
GRETNA LA
70056-7903
US

IV. Provider business mailing address

617 BANNERWOOD DR
GRETNA LA
70056-7903
US

V. Phone/Fax

Practice location:
  • Phone: 504-231-7563
  • Fax:
Mailing address:
  • Phone: 504-231-7563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: