Provider Demographics
NPI:1568744829
Name:CLARK, EMILY KAYE (APRN)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:KAYE
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:K
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:3821 VINCENT STATION DR
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9315
Practice Address - Country:US
Practice Address - Phone:270-478-5334
Practice Address - Fax:270-216-6920
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1102616363L00000X
KY3007200363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100190860Medicaid
KYK022590Medicare PIN