Basic Information
| Provider Information | |||||||||
| NPI: | 1538152996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKSON | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RNBC FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19375 HUSK RD | ||||||||
| Address2: | |||||||||
| City: | LACLEDE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 646517187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6609632354 | ||||||||
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| Practice Location | |||||||||
| Address1: | 307 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652811037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6603886446 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 01/07/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 072707 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 428524607 | 05 | MO | MEDICAID |