Basic Information
| Provider Information | |||||||||
| NPI: | 1336535624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAYSAH CLARK | ||||||||
| FirstName: | KOLU | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 TOLLGATE RD | ||||||||
| Address2: | PROFESSIONAL REVENUE CYCLE AND CREDENTIALING | ||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028862759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012730641 | ||||||||
| FaxNumber: | 4012732919 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 TOLL GATE RD | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028862759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017377010 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2015 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN2269378 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP2300X | APRN00086 | RI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LP2300X | RN2269378 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LG0600X | APRN00086 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.