Provider Demographics
NPI:1932575743
Name:CLARK, KERRY (AGNP-BC)
Entity Type:Individual
Prefix:MS
First Name:KERRY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:4660 KENMORE AVENUE, SUITE 305 & 500
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1306
Practice Address - Country:US
Practice Address - Phone:703-988-4683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-15
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1038780207R00000X
VA0024178999363LG0600X, 363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1932575743Medicaid
VA30016021870002Medicaid