Provider Demographics
NPI:1124101332
Name:CLARK, GINA K (ARNP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:K
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-780-2497
Mailing Address - Fax:270-783-3750
Practice Address - Street 1:990 WILKINSON TRCE STE 100
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-3404
Practice Address - Country:US
Practice Address - Phone:270-781-4043
Practice Address - Fax:270-781-4196
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2015-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3560P363L00000X
KY3003560363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
H06248Medicare UPIN