Provider Demographics
NPI:1174912406
Name:CLARK, GINA (APRN)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 RUNNYMEDE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-6144
Mailing Address - Country:US
Mailing Address - Phone:502-657-1076
Mailing Address - Fax:888-959-2460
Practice Address - Street 1:4200 GARDINER VIEW AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1877
Practice Address - Country:US
Practice Address - Phone:502-456-0494
Practice Address - Fax:502-456-0496
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008878363L00000X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology