Provider Demographics
NPI:1538152996
Name:CLARKSON, SANDRA J (RNBC FNP)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:J
Last Name:CLARKSON
Suffix:
Gender:F
Credentials:RNBC FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19375 HUSK RD
Mailing Address - Street 2:
Mailing Address - City:LACLEDE
Mailing Address - State:MO
Mailing Address - Zip Code:64651-7187
Mailing Address - Country:US
Mailing Address - Phone:660-963-2354
Mailing Address - Fax:
Practice Address - Street 1:307 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MO
Practice Address - Zip Code:65281-1037
Practice Address - Country:US
Practice Address - Phone:660-388-6446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO072707363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428524607Medicaid
S35629Medicare UPIN
MO000080157Medicare ID - Type Unspecified