Provider Demographics
NPI:1366083974
Name:CLARK, KAMRYN T
Entity type:Individual
Prefix:
First Name:KAMRYN
Middle Name:T
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5644 HIGHWAY 29 S
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71801-1046
Mailing Address - Country:US
Mailing Address - Phone:870-703-9104
Mailing Address - Fax:
Practice Address - Street 1:508 N 2ND ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-3925
Practice Address - Country:US
Practice Address - Phone:870-455-0134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator