Provider Demographics
NPI:1629782669
Name:CLARK, ANGELA
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 N EXPOSITION ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-5902
Mailing Address - Country:US
Mailing Address - Phone:316-618-1252
Mailing Address - Fax:
Practice Address - Street 1:560 N EXPOSITION ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-5902
Practice Address - Country:US
Practice Address - Phone:316-618-1252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3064235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist