Provider Demographics
NPI:1174182281
Name:CLARK, KATHLEEN A (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5602 ERIC SUSTAR LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-6721
Mailing Address - Country:US
Mailing Address - Phone:704-953-0287
Mailing Address - Fax:
Practice Address - Street 1:1365 WESTGATE CENTER DR STE G1
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2980
Practice Address - Country:US
Practice Address - Phone:336-659-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011854363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner