Provider Demographics
NPI:1114632130
Name:CLARK, CHANDLER (NP)
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5835 MISSION RD
Mailing Address - Street 2:
Mailing Address - City:FAIRWAY
Mailing Address - State:KS
Mailing Address - Zip Code:66205-3167
Mailing Address - Country:US
Mailing Address - Phone:913-226-0342
Mailing Address - Fax:
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3241
Practice Address - Country:US
Practice Address - Phone:816-932-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185283363LN0000X
MO2024036070363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal