Provider Demographics
NPI:1508405028
Name:CLARK, KIMBERLY ANN (RN MSN FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN MSN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 NW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-2608
Mailing Address - Country:US
Mailing Address - Phone:580-678-8081
Mailing Address - Fax:
Practice Address - Street 1:307 EAST 9TH STREET
Practice Address - Street 2:
Practice Address - City:WHEELER
Practice Address - State:TX
Practice Address - Zip Code:79096-1030
Practice Address - Country:US
Practice Address - Phone:580-558-8543
Practice Address - Fax:630-570-6352
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK95760163WC0400X
OKF05200738363LF0000X
TX1014028363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0400XNursing Service ProvidersRegistered NurseCase Management