Basic Information
| Provider Information | |||||||||
| NPI: | 1275859761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DAPHNE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708586655 | ||||||||
| FaxNumber: | 2708584607 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 MEDICAL LOOP | ||||||||
| Address2: | STE 3 | ||||||||
| City: | WHITLEY CITY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426534382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063765391 | ||||||||
| FaxNumber: | 6063763326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2010 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3006424 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 6424P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100111350 | 05 | KY | MEDICAID |