Provider Demographics
NPI:1538936489
Name:CLARK, LAURA ELIZABETH (LPN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ELIZABETH
Other - Last Name:LEFEBVRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18458 POTTER RD
Mailing Address - Street 2:
Mailing Address - City:CLATSKANIE
Mailing Address - State:OR
Mailing Address - Zip Code:97016-2119
Mailing Address - Country:US
Mailing Address - Phone:503-396-3737
Mailing Address - Fax:
Practice Address - Street 1:305 PACIFIC AVE S STE C
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1638
Practice Address - Country:US
Practice Address - Phone:360-644-1047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61013657164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse