Provider Demographics
NPI:1043707854
Name:CLARK, BRIANNA YVONNE (DO)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:YVONNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 S MAIDEN LN
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-3084
Mailing Address - Country:US
Mailing Address - Phone:417-782-6200
Mailing Address - Fax:417-782-6210
Practice Address - Street 1:530 S MAIDEN LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-3084
Practice Address - Country:US
Practice Address - Phone:417-782-6200
Practice Address - Fax:417-782-6210
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X, 390200000X
KS05-45999207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program