Provider Demographics
NPI:1912363946
Name:CLARK, KAILEY (ARNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KAILEY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4612 N HABANA AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7101
Mailing Address - Country:US
Mailing Address - Phone:813-875-9000
Mailing Address - Fax:813-874-3278
Practice Address - Street 1:4612 N HABANA AVE FL 2
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7101
Practice Address - Country:US
Practice Address - Phone:813-875-9000
Practice Address - Fax:813-874-3278
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9320963363LF0000X
FLARNP9320963363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016597100Medicaid