Provider Demographics
NPI:1346989761
Name:CLARK, KIERSTIN
Entity Type:Individual
Prefix:
First Name:KIERSTIN
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 1:580 COURT ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-1718
Mailing Address - Country:US
Mailing Address - Phone:603-354-5400
Mailing Address - Fax:
Practice Address - Street 1:580 COURT ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-1718
Practice Address - Country:US
Practice Address - Phone:603-354-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NH1908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant