Provider Demographics
NPI:1275859761
Name:CLARK, DAPHNE ANN (APRN)
Entity Type:Individual
Prefix:
First Name:DAPHNE
Middle Name:ANN
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:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-858-6655
Mailing Address - Fax:270-858-4607
Practice Address - Street 1:1900 N HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653-4119
Practice Address - Country:US
Practice Address - Phone:606-376-3326
Practice Address - Fax:888-960-2041
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006424363LF0000X
KY6424P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100111350Medicaid
12090990OtherCAQH