Provider Demographics
NPI:1063010312
Name:CLARK, KELSEY LEIGH-ANN (CRNP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:LEIGH-ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22099 US HIGHWAY 72 STE C
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35613-2670
Mailing Address - Country:US
Mailing Address - Phone:256-206-8122
Mailing Address - Fax:256-270-0108
Practice Address - Street 1:22099 US HIGHWAY 72 STE C
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613-2670
Practice Address - Country:US
Practice Address - Phone:256-206-8122
Practice Address - Fax:256-270-0108
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-150045363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily