Provider Demographics
NPI:1386669612
Name:CLARK, JULIE E (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1900 SWIFT AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3445
Mailing Address - Country:US
Mailing Address - Phone:816-221-5050
Mailing Address - Fax:816-471-1247
Practice Address - Street 1:2800 CLAY EDWARDS DR
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3220
Practice Address - Country:US
Practice Address - Phone:816-691-1765
Practice Address - Fax:816-471-1247
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110806163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH90000024Medicare PIN