Provider Demographics
NPI:1093593600
Name:CLARK, PAUL RICHARD (RN, PHD, MA, FAEN)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:RICHARD
Last Name:CLARK
Suffix:
Gender:M
Credentials:RN, PHD, MA, FAEN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SAINT ANTHONY DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT SAINT FRANCIS
Mailing Address - State:IN
Mailing Address - Zip Code:47146-9001
Mailing Address - Country:US
Mailing Address - Phone:210-789-6031
Mailing Address - Fax:
Practice Address - Street 1:555 S FLOYD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3822
Practice Address - Country:US
Practice Address - Phone:210-789-6031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28193134A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse