Provider Demographics
NPI:1942590005
Name:CLARK, KENDRA E (CPS)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5511
Mailing Address - Country:US
Mailing Address - Phone:307-633-7213
Mailing Address - Fax:307-633-7202
Practice Address - Street 1:2600 E 18TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5511
Practice Address - Country:US
Practice Address - Phone:307-633-7213
Practice Address - Fax:307-633-7202
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator