Provider Demographics
NPI:1669288981
Name:CLARK, KATHY LETT
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:LETT
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:PO BOX 803
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-0803
Mailing Address - Country:US
Mailing Address - Phone:303-550-0832
Mailing Address - Fax:
Practice Address - Street 1:340 EXEMPLA CIR STE 400
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3384
Practice Address - Country:US
Practice Address - Phone:303-550-0832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1627811208600000X, 364SP2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP2800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerioperative
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty