Provider Demographics
NPI:1619221884
Name:CLARK, SARAH ELIZABETH (APRN)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ELIZABETH
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 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:1023 NEW MOODY LN
Practice Address - Street 2:SUITE 102
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031
Practice Address - Country:US
Practice Address - Phone:502-222-0598
Practice Address - Fax:502-222-7446
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007451363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100224760Medicaid