Provider Demographics
NPI:1245566272
Name:CLARK, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2924
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-2984
Mailing Address - Country:US
Mailing Address - Phone:301-609-9887
Mailing Address - Fax:301-609-7284
Practice Address - Street 1:6100 RADIO STATION ROAD
Practice Address - Street 2:
Practice Address - City:LAPLATA
Practice Address - State:MD
Practice Address - Zip Code:20646
Practice Address - Country:US
Practice Address - Phone:301-609-9887
Practice Address - Fax:301-609-7284
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD589561800Medicaid