Basic Information
| Provider Information | |||||||||
| NPI: | 1720591076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | HILLARY | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407430936 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 192 LONDON SHOPPING CTR STE 2 | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063307370 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2017 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3011821 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100508480 | 05 | KY | MEDICAID |