Provider Demographics
NPI:1629572698
Name:CLARK, KARYN KELLY (BS, BA)
Entity Type:Individual
Prefix:
First Name:KARYN
Middle Name:KELLY
Last Name:CLARK
Suffix:
Gender:F
Credentials:BS, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1281
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-0157
Mailing Address - Country:US
Mailing Address - Phone:307-851-3955
Mailing Address - Fax:
Practice Address - Street 1:625 E MADISON AVE STE 6
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4712
Practice Address - Country:US
Practice Address - Phone:307-851-3955
Practice Address - Fax:307-857-6974
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator