Provider Demographics
NPI:1043896079
Name:CLARK, HUNTER KELSEY
Entity Type:Individual
Prefix:
First Name:HUNTER
Middle Name:KELSEY
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 FREDERICKSBURG DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6376
Mailing Address - Country:US
Mailing Address - Phone:423-306-1716
Mailing Address - Fax:
Practice Address - Street 1:809 LAMONT ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5453
Practice Address - Country:US
Practice Address - Phone:423-306-1716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-21
Last Update Date:2021-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN218160163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse