Provider Demographics
NPI:1679915664
Name:CLARK, CAROLYN GAY (NP-C)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:GAY
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 STATE HIGHWAY 248
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-8398
Mailing Address - Country:US
Mailing Address - Phone:417-332-3639
Mailing Address - Fax:417-332-3641
Practice Address - Street 1:1232 BRANSON HILLS PKWY STE 106
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-4189
Practice Address - Country:US
Practice Address - Phone:417-332-3639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013024407363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily