Provider Demographics
NPI:1841557428
Name:CLARK, KATHERINE (CPNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 CLARK WAY
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304
Mailing Address - Country:US
Mailing Address - Phone:650-688-3644
Mailing Address - Fax:650-688-3669
Practice Address - Street 1:650 CLARK WAY
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304
Practice Address - Country:US
Practice Address - Phone:650-688-3644
Practice Address - Fax:650-688-3669
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005585363LP0200X, 363LP0808X
CA23185363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health