Healthcare Provider Details

I. General information

NPI: 1255808085
Provider Name (Legal Business Name): AMANDA M CLARK ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 03/20/2021
Certification Date: 03/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 TIMBERLINE CT APT F105
RUSTON LA
71270
US

IV. Provider business mailing address

2301 TIMBERLINE CT APT F105
RUSTON LA
71270-5292
US

V. Phone/Fax

Practice location:
  • Phone: 210-827-3950
  • Fax:
Mailing address:
  • Phone: 210-827-3950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number321844
License Number StateLA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1255808085
Identifier TypeOTHER
Identifier StateTX
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: