Provider Demographics
NPI:1669878443
Name:CLARK, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MASTERS DRIVE
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464
Mailing Address - Country:US
Mailing Address - Phone:484-250-3932
Mailing Address - Fax:
Practice Address - Street 1:724 N CHARLOTTE ST
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464-4607
Practice Address - Country:US
Practice Address - Phone:610-323-1837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN664213163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse