Provider Demographics
NPI:1053651869
Name:CLARK, KIMBERLY GAIL
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GAIL
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 1:750 N COMMONS DR STE 200
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7940
Mailing Address - Country:US
Mailing Address - Phone:630-303-5380
Mailing Address - Fax:630-303-5385
Practice Address - Street 1:272 WESTLAKE RD STE 2
Practice Address - Street 2:
Practice Address - City:HARDY
Practice Address - State:VA
Practice Address - Zip Code:24101-3967
Practice Address - Country:US
Practice Address - Phone:540-721-7798
Practice Address - Fax:540-721-8345
Is Sole Proprietor?:No
Enumeration Date:2013-02-15
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2101001640237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist