Provider Demographics
NPI:1932404761
Name:CLARK, JUDY KATE (APRN)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:KATE
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:KATE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 73652
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0002
Mailing Address - Country:US
Mailing Address - Phone:859-313-2758
Mailing Address - Fax:859-276-5939
Practice Address - Street 1:2740A BATTLEFIELD MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-8332
Practice Address - Country:US
Practice Address - Phone:859-986-0302
Practice Address - Fax:859-986-0315
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006764363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner