Provider Demographics
NPI:1285171157
Name:CLARK, KAYLA R (AT)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:R
Last Name:CLARK
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2488 E 81ST ST STE 290
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4265
Mailing Address - Country:US
Mailing Address - Phone:918-927-3737
Mailing Address - Fax:918-927-3193
Practice Address - Street 1:2488 E 81ST ST STE 290
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4265
Practice Address - Country:US
Practice Address - Phone:918-494-2665
Practice Address - Fax:918-927-3201
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7382255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer