Provider Demographics
NPI:1376220798
Name:CLARK, KATHERINE SUE (APRN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:SUE
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 1:3791 S CRANBERRY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286-4310
Mailing Address - Country:US
Mailing Address - Phone:941-266-3681
Mailing Address - Fax:
Practice Address - Street 1:7700 US HIGHWAY 158
Practice Address - Street 2:
Practice Address - City:STOKESDALE
Practice Address - State:NC
Practice Address - Zip Code:27357-9346
Practice Address - Country:US
Practice Address - Phone:800-226-8874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11023419363LF0000X
GAGAA-NP001335363LF0000X
NC501887363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily