Provider Demographics
NPI:1548297708
Name:CLARK, PAULETTE JEAN (CRNA)
Entity type:Individual
Prefix:MS
First Name:PAULETTE
Middle Name:JEAN
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:PAULETTE
Other - Middle Name:JEAN
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 447
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:NE
Mailing Address - Zip Code:68620-0447
Mailing Address - Country:US
Mailing Address - Phone:402-395-6897
Mailing Address - Fax:
Practice Address - Street 1:2439 260TH ST
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:NE
Practice Address - Zip Code:68620-5584
Practice Address - Country:US
Practice Address - Phone:402-395-6897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE26343163W00000X
NE100340367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE277789Medicare PIN
NE096576003Medicare PIN