Provider Demographics
NPI:1073687224
Name:CLARK, KRISTA M
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:M
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 1:810 HADLEY AVE
Mailing Address - Street 2:
Mailing Address - City:OLD HICKORY
Mailing Address - State:TN
Mailing Address - Zip Code:37138-3121
Mailing Address - Country:US
Mailing Address - Phone:615-847-8000
Mailing Address - Fax:615-847-4693
Practice Address - Street 1:810 HADLEY AVE
Practice Address - Street 2:
Practice Address - City:OLD HICKORY
Practice Address - State:TN
Practice Address - Zip Code:37138-3121
Practice Address - Country:US
Practice Address - Phone:615-847-8000
Practice Address - Fax:615-847-4693
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4018836OtherBCBS OF TN
TN1454254Medicaid
TN1307810001Medicare NSC