Basic Information
| Provider Information | |||||||||
| NPI: | 1851739874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | GENEVA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 WHISPERING RIDGE CV | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380604639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014661912 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3041 GETWELL RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381183737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013751050 | ||||||||
| FaxNumber: | 9013751588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2013 | ||||||||
| LastUpdateDate: | 06/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 65206 | TN | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.