Provider Demographics
NPI:1245259167
Name:CLARK, KATHLEEN A (FNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-3615
Mailing Address - Country:US
Mailing Address - Phone:260-919-3900
Mailing Address - Fax:260-919-3913
Practice Address - Street 1:1100 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-3615
Practice Address - Country:US
Practice Address - Phone:260-919-3900
Practice Address - Fax:260-919-3913
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN74001171A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200334940Medicaid
INP34495Medicare UPIN
IN200334940Medicaid