Provider Demographics
NPI:1053735464
Name:CLARK, LEE ANN (RN)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 296TH ST E
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:WA
Mailing Address - Zip Code:98580-7648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15305 WALLER RD E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98446-1533
Practice Address - Country:US
Practice Address - Phone:253-683-8768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00137963163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool