Provider Demographics
NPI:1699846436
Name:CLARK, MARY KATHLYN (FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHLYN
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:103 LICHEN DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:SC
Mailing Address - Zip Code:29697-8514
Mailing Address - Country:US
Mailing Address - Phone:864-840-9128
Mailing Address - Fax:864-231-9468
Practice Address - Street 1:620 C CONGAREE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607
Practice Address - Country:US
Practice Address - Phone:864-254-9477
Practice Address - Fax:864-254-9896
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN1171363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0553Medicaid