Provider Demographics
NPI:1598778854
Name:CLARK, TRACY A (ARNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E 104TH ST
Mailing Address - Street 2:MS 400S
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131
Mailing Address - Country:US
Mailing Address - Phone:816-502-8752
Mailing Address - Fax:816-932-9670
Practice Address - Street 1:21624 MIDLAND DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66218-9064
Practice Address - Country:US
Practice Address - Phone:913-643-0075
Practice Address - Fax:913-643-0077
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45920363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily