Provider Demographics
NPI:1922718550
Name:CLARK, MICHAEL JAMES (FNP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:CLARK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6469 US HIGHWAY 231
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:KY
Mailing Address - Zip Code:42376-9018
Mailing Address - Country:US
Mailing Address - Phone:270-993-6825
Mailing Address - Fax:
Practice Address - Street 1:6469 US HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:KY
Practice Address - Zip Code:42376-9018
Practice Address - Country:US
Practice Address - Phone:270-993-6825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017548363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily