Provider Demographics
NPI:1487943783
Name:CLARK, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
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 1:8792 N WHITE TAIL TRL
Mailing Address - Street 2:
Mailing Address - City:MC CORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-9307
Mailing Address - Country:US
Mailing Address - Phone:317-335-1337
Mailing Address - Fax:
Practice Address - Street 1:1481 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2803
Practice Address - Country:US
Practice Address - Phone:317-554-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28159554A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse