Provider Demographics
NPI:1760638290
Name:CLARK, KIM MICHELE (RN)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MICHELE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6820 NW GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-2706
Mailing Address - Country:US
Mailing Address - Phone:541-753-0708
Mailing Address - Fax:
Practice Address - Street 1:6820 NW GRANDVIEW DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-2706
Practice Address - Country:US
Practice Address - Phone:541-753-0708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR095006090RN163W00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No172V00000XOther Service ProvidersCommunity Health Worker