Basic Information
| Provider Information | |||||||||
| NPI: | 1932404761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | JUDY | ||||||||
| MiddleName: | KATE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | JUDY | ||||||||
| OtherMiddleName: | KATE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 73652 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593132758 | ||||||||
| FaxNumber: | 8592765939 | ||||||||
| Practice Location | |||||||||
| Address1: | 2740A BATTLEFIELD MEMORIAL HWY | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404038332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599860302 | ||||||||
| FaxNumber: | 8599860315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2011 | ||||||||
| LastUpdateDate: | 08/17/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3006764 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.