Provider Demographics
NPI:1750619995
Name:STOUDEMIRE, KLARISA NICOLE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:KLARISA
Middle Name:NICOLE
Last Name:STOUDEMIRE
Suffix:
Gender:
Credentials:ARNP
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776347
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6347
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:234 E GRAY ST STE 154
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1903
Practice Address - Country:US
Practice Address - Phone:502-629-2500
Practice Address - Fax:502-629-2055
Is Sole Proprietor?:No
Enumeration Date:2009-11-30
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006498363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY229581OtherSIHO
KY7100172130Medicaid
KYK008131OtherMEDICARE
IN300007238Medicaid
KY50132455OtherPASSPORT
KY000001092683OtherANTHEM