Provider Demographics
NPI:1679836605
Name:CLARK, KRISTINA M (NP)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:700 MCCLELLAN ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-1019
Practice Address - Country:US
Practice Address - Phone:518-372-5637
Practice Address - Fax:518-372-1384
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2018-01-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY501366163W00000X
NY382310363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03494502Medicaid
NY120919000071OtherFIDELIS CARE NY