Provider Demographics
NPI:1013474410
Name:CLARK, KELLY PATRICIA (LPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:PATRICIA
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PINE DR E
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-9229
Mailing Address - Country:US
Mailing Address - Phone:517-394-6484
Mailing Address - Fax:
Practice Address - Street 1:55 PINE DR E
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-9229
Practice Address - Country:US
Practice Address - Phone:517-394-6484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703110786164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse