Provider Demographics
NPI:1093285017
Name:CLARK, CAITLIN E (CRNA)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:E
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 411895
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-1895
Mailing Address - Country:US
Mailing Address - Phone:913-647-4100
Mailing Address - Fax:913-258-2509
Practice Address - Street 1:9100 W 74TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-4004
Practice Address - Country:US
Practice Address - Phone:913-632-2230
Practice Address - Fax:913-632-2297
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS119760163W00000X
KS557656367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse