Provider Demographics
NPI:1720976129
Name:CLARK, CAILIN R
Entity type:Individual
Prefix:
First Name:CAILIN
Middle Name:R
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 1:7434 MCAULIFFE LOOP APT A
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-6028
Mailing Address - Country:US
Mailing Address - Phone:719-505-5441
Mailing Address - Fax:
Practice Address - Street 1:7434 MCAULIFFE LOOP APT A
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-6028
Practice Address - Country:US
Practice Address - Phone:719-505-5441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-25
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37619363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care