Provider Demographics
NPI:1275272940
Name:CLARK, BROOKLYN N (APSS)
Entity Type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:N
Last Name:CLARK
Suffix:
Gender:F
Credentials:APSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 BIG BEAR LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-2053
Mailing Address - Country:US
Mailing Address - Phone:859-317-3171
Mailing Address - Fax:
Practice Address - Street 1:561 BREKENRIDGE STREET
Practice Address - Street 2:202
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508
Practice Address - Country:US
Practice Address - Phone:859-317-3171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty