Provider Demographics
NPI:1346693868
Name:CLARK, KERESSA L (NP)
Entity Type:Individual
Prefix:
First Name:KERESSA
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:111 W STONE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-6027
Practice Address - Country:US
Practice Address - Phone:423-224-3701
Practice Address - Fax:423-224-3709
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024173732363LF0000X
TN21571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVL791B288Medicare PIN
TN10350I7991Medicare PIN