=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336100130
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA LYNN CLARK CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2006
-----------------------------------------------------
Last Update Date | 07/25/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4370 W MAIN STREET
-----------------------------------------------------
City | DOTHAN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-793-5000
-----------------------------------------------------
Fax | 334-615-8428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6907
-----------------------------------------------------
City | DOTHAN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-793-5000
-----------------------------------------------------
Fax | 334-615-8428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 1054427
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------