Provider Demographics
NPI:1326417023
Name:CLARK, HALEY
Entity Type:Individual
Prefix:
First Name:HALEY
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 1:436 LOGAN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40484-9524
Mailing Address - Country:US
Mailing Address - Phone:859-324-5746
Mailing Address - Fax:
Practice Address - Street 1:100 JAY ST
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:KY
Practice Address - Zip Code:40484-7511
Practice Address - Country:US
Practice Address - Phone:606-365-5746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC419363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant