Provider Demographics
NPI:1043678170
Name:CLARK, KATHERINE (AGNP-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 OTTER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WHITSETT
Mailing Address - State:NC
Mailing Address - Zip Code:27377-9322
Mailing Address - Country:US
Mailing Address - Phone:918-691-1134
Mailing Address - Fax:
Practice Address - Street 1:940 GOLF HOUSE CT E
Practice Address - Street 2:
Practice Address - City:WHITSETT
Practice Address - State:NC
Practice Address - Zip Code:27377-9296
Practice Address - Country:US
Practice Address - Phone:336-449-9838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC234589363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care