Provider Demographics
NPI:1851607162
Name:CLARK, KERRY LEANN
Entity Type:Individual
Prefix:MRS
First Name:KERRY
Middle Name:LEANN
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 1:1217 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:KS
Mailing Address - Zip Code:67357-5125
Mailing Address - Country:US
Mailing Address - Phone:620-421-2431
Mailing Address - Fax:620-423-0158
Practice Address - Street 1:814 WALNUT ST
Practice Address - Street 2:
Practice Address - City:CHETOPA
Practice Address - State:KS
Practice Address - Zip Code:67336-8990
Practice Address - Country:US
Practice Address - Phone:620-236-7248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01713225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant