Provider Demographics
NPI:1104443258
Name:CLARK, KILMENY
Entity type:Individual
Prefix:
First Name:KILMENY
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 1:1800 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3810
Mailing Address - Country:US
Mailing Address - Phone:217-464-2973
Mailing Address - Fax:
Practice Address - Street 1:300 W OAK ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1400
Practice Address - Country:US
Practice Address - Phone:618-453-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-05
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008097363A00000X
WI5318-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant