Provider Demographics
NPI:1851629422
Name:CLARK, DENNIS ERIN
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:ERIN
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W MCDONALD ST
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:KS
Mailing Address - Zip Code:66021-2430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 W MCDONALD ST
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:KS
Practice Address - Zip Code:66021-2430
Practice Address - Country:US
Practice Address - Phone:913-882-9704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-86682-081163W00000X
MO2009001167163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse