Provider Demographics
NPI:1881403327
Name:CLARK, NATASHA K
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:K
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 1:7015 E 618 RD
Mailing Address - Street 2:
Mailing Address - City:PEGGS
Mailing Address - State:OK
Mailing Address - Zip Code:74452-2079
Mailing Address - Country:US
Mailing Address - Phone:918-882-2684
Mailing Address - Fax:
Practice Address - Street 1:231 E GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-2436
Practice Address - Country:US
Practice Address - Phone:918-825-1405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37V136193062376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide