Healthcare Provider Details

I. General information

NPI: 1689066367
Provider Name (Legal Business Name): SHELLEY B CLARK LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2015
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 SUNSCOPE DR
OCEAN SPRINGS MS
39564-8690
US

IV. Provider business mailing address

6520 SUNSCOPE DR
OCEAN SPRINGS MS
39564-8690
US

V. Phone/Fax

Practice location:
  • Phone: 228-875-1177
  • Fax: 228-872-4009
Mailing address:
  • Phone: 228-875-1177
  • Fax: 228-872-4009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberPTA4100
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: