Provider Demographics
NPI:1134754948
Name:CLARK, KERRY S (CRNP)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:S
Last Name:CLARK
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5947 HIGHWAY 269
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:AL
Mailing Address - Zip Code:35580-3847
Mailing Address - Country:US
Mailing Address - Phone:205-686-5113
Mailing Address - Fax:205-265-2994
Practice Address - Street 1:200 CARRAWAY DR STE B1
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:AL
Practice Address - Zip Code:35594-5073
Practice Address - Country:US
Practice Address - Phone:205-487-7888
Practice Address - Fax:205-487-7892
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-113412363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily