Provider Demographics
NPI:1073581518
Name:CLARK, KAREN SHEPARD (RN, MS, CRNP, ACHPN)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:SHEPARD
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN, MS, CRNP, ACHPN
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:LEIDHECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 E END BLVD
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711-0030
Mailing Address - Country:US
Mailing Address - Phone:570-888-6803
Mailing Address - Fax:570-888-2025
Practice Address - Street 1:1111 E END BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0030
Practice Address - Country:US
Practice Address - Phone:570-888-6803
Practice Address - Fax:570-888-2025
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP003017H363L00000X, 363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0071777100002Medicaid
PA1661103OtherHIGHMARK BLUE SHIELD
PAR98102OtherHEALTHAMERICA
PAR98102OtherHEALTHAMERICA
PA0071777100002Medicaid
R98102Medicare UPIN