Provider Demographics
NPI:1164819504
Name:AUSTIN-CLARK, MARILYN
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:AUSTIN-CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:AUSTIN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:624 E NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-3411
Mailing Address - Country:US
Mailing Address - Phone:405-471-4914
Mailing Address - Fax:
Practice Address - Street 1:624 E NOBLE AVE
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-3411
Practice Address - Country:US
Practice Address - Phone:405-471-4914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK81876363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK12150625001972Medicaid