Provider Demographics
NPI:1265094478
Name:CLARK, KRISTYN
Entity type:Individual
Prefix:
First Name:KRISTYN
Middle Name:
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 1:210 S THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-4239
Mailing Address - Country:US
Mailing Address - Phone:479-927-1044
Mailing Address - Fax:
Practice Address - Street 1:210 S THOMPSON ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-4239
Practice Address - Country:US
Practice Address - Phone:479-927-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR120097363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care