Provider Demographics
NPI:1972165496
Name:CLARK, KATELYN
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
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 1:107 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:GALLITZIN
Mailing Address - State:PA
Mailing Address - Zip Code:16641-1115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 HOWARD AVE STE 1
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4728
Practice Address - Country:US
Practice Address - Phone:814-889-2708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-04
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060775363AM0700X
PAOA004978363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical