Provider Demographics
NPI:1730579152
Name:CLARK, ELIZABETH ANN (APN)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11449
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4005
Mailing Address - Country:US
Mailing Address - Phone:479-709-1924
Mailing Address - Fax:479-709-7499
Practice Address - Street 1:1500 DODSON AVE
Practice Address - Street 2:SUITE 60
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-5182
Practice Address - Country:US
Practice Address - Phone:479-709-7325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-24
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004327363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily