Provider Demographics
NPI:1770535502
Name:CLARK, CAROL (CNP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9015 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-2016
Mailing Address - Country:US
Mailing Address - Phone:317-898-3166
Mailing Address - Fax:317-898-4219
Practice Address - Street 1:9015 E 17TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2016
Practice Address - Country:US
Practice Address - Phone:317-898-3166
Practice Address - Fax:317-898-4219
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000959A363LC1500X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200307710Medicaid
INP01016729OtherRR MEDICARE PTAN
IN200307710Medicaid
INP01016729OtherRR MEDICARE PTAN
IN213820DMedicare PIN
IN192980BMedicare ID - Type Unspecified