Provider Demographics
NPI:1265665467
Name:CLARKE, KATHRYN L (FNP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:CLARKE
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:PO BOX 910221
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-0221
Mailing Address - Country:US
Mailing Address - Phone:520-519-7700
Mailing Address - Fax:
Practice Address - Street 1:1845 W ORANGE GROVE RD BLDG 2
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1144
Practice Address - Country:US
Practice Address - Phone:520-531-8967
Practice Address - Fax:520-742-7180
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3406363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZRN132004OtherAZ RN LICENSE
AZ455938Medicaid
AZAP3406OtherAZ NP LICENSE