Provider Demographics
NPI:1699369645
Name:CLARK, KIERA ELISE (NP)
Entity Type:Individual
Prefix:
First Name:KIERA
Middle Name:ELISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 MILLTOWN RD
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:NC
Mailing Address - Zip Code:27974-6220
Mailing Address - Country:US
Mailing Address - Phone:301-904-4377
Mailing Address - Fax:
Practice Address - Street 1:1134 N ROAD ST STE 9
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3467
Practice Address - Country:US
Practice Address - Phone:252-331-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-21
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5014172363LF0000X, 207RC0000X
NC245136207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease