Provider Demographics
NPI:1346776390
Name:CLARK, ANGELA (APRN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
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 1:523 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1765
Mailing Address - Country:US
Mailing Address - Phone:270-393-8418
Mailing Address - Fax:270-393-8440
Practice Address - Street 1:523 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1765
Practice Address - Country:US
Practice Address - Phone:270-393-8418
Practice Address - Fax:270-393-8440
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011302363LP2300X, 363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily