Provider Demographics
NPI:1114520749
Name:CLARK, VALISA ANN (APRN)
Entity Type:Individual
Prefix:
First Name:VALISA
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:VALISA
Other - Middle Name:ANN
Other - Last Name:CULVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:913 N DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2503
Mailing Address - Country:US
Mailing Address - Phone:270-706-5171
Mailing Address - Fax:270-706-5538
Practice Address - Street 1:913 N DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2503
Practice Address - Country:US
Practice Address - Phone:270-706-5171
Practice Address - Fax:270-706-5538
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015341363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily