=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497238612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MACIE M CLARK LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2018
-----------------------------------------------------
Last Update Date | 09/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1564 S WASHINGTON ST
-----------------------------------------------------
City | DU QUOIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62832-3849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-542-8702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4241 HIGHWAY 14 W
-----------------------------------------------------
City | CHRISTOPHER
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62822-1037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 043125988
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------