Healthcare Provider Details

I. General information

NPI: 1619488855
Provider Name (Legal Business Name): LAURA CLARK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E US HIGHWAY 60
MOUNTAIN VIEW MO
65548-7381
US

IV. Provider business mailing address

104 E US HIGHWAY 60
MOUNTAIN VIEW MO
65548-7381
US

V. Phone/Fax

Practice location:
  • Phone: 417-934-2251
  • Fax:
Mailing address:
  • Phone: 417-934-2251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015028255
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: