Provider Demographics
NPI:1629802772
Name:CLARK, ANNIE
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4221
Mailing Address - Country:US
Mailing Address - Phone:870-732-1191
Mailing Address - Fax:
Practice Address - Street 1:108 W TYLER AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4221
Practice Address - Country:US
Practice Address - Phone:870-732-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2025-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36624363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily