Provider Demographics
NPI:1063841534
Name:FEIFERT CLARK, KRISTEN NANCY (MSN CNM)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NANCY
Last Name:FEIFERT CLARK
Suffix:
Gender:F
Credentials:MSN CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 WEST ST STE 25
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01527-2622
Mailing Address - Country:US
Mailing Address - Phone:508-917-6720
Mailing Address - Fax:508-917-6721
Practice Address - Street 1:22 WEST ST STE 25
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:MA
Practice Address - Zip Code:01527-2622
Practice Address - Country:US
Practice Address - Phone:508-917-6720
Practice Address - Fax:508-917-6721
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN242199367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110099291AOtherMEDICAID PTAN
MAS100140020OtherMEDICARE PTAN