Healthcare Provider Details

I. General information

NPI: 1386142685
Provider Name (Legal Business Name): MRS. RACHEL NACOLE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2018
Last Update Date: 02/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W 10TH ST
ROLLA MO
65401-2905
US

IV. Provider business mailing address

13005 ARLINGTON RD
NEWBURG MO
65550-9063
US

V. Phone/Fax

Practice location:
  • Phone: 573-458-7800
  • Fax:
Mailing address:
  • Phone: 573-465-2268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2018001797
License Number StateMO

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: