Provider Demographics
NPI:1013497304
Name:CLARK, KELLY ANN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
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 1:2498 WENONA DR
Mailing Address - Street 2:
Mailing Address - City:WIXOM
Mailing Address - State:MI
Mailing Address - Zip Code:48393-2199
Mailing Address - Country:US
Mailing Address - Phone:248-231-3861
Mailing Address - Fax:
Practice Address - Street 1:2498 WENONA DR
Practice Address - Street 2:
Practice Address - City:WIXOM
Practice Address - State:MI
Practice Address - Zip Code:48393-2199
Practice Address - Country:US
Practice Address - Phone:248-231-3861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator