Provider Demographics
NPI:1013452879
Name:CLARK, CRYSTAL LEA (APRN-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEA
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 SW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66611-1200
Mailing Address - Country:US
Mailing Address - Phone:785-379-4600
Mailing Address - Fax:
Practice Address - Street 1:1700 SW 7TH ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-2489
Practice Address - Country:US
Practice Address - Phone:785-295-8000
Practice Address - Fax:785-295-5483
Is Sole Proprietor?:No
Enumeration Date:2017-01-03
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-77518-082363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily