Provider Demographics
NPI:1477374874
Name:CLARK, CHANNEL TRENISE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:CHANNEL
Middle Name:TRENISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 NW KESSLER DR APT 307
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-4173
Mailing Address - Country:US
Mailing Address - Phone:816-289-1223
Mailing Address - Fax:
Practice Address - Street 1:237 NW KESSLER DR APT 307
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64081-4173
Practice Address - Country:US
Practice Address - Phone:816-289-1223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004022119163W00000X
MO2024039915363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse