Provider Demographics
NPI:1285890939
Name:JOHNSON-CLARK, KATELYN ELIZABETH (DO)
Entity type:Individual
Prefix:DR
First Name:KATELYN
Middle Name:ELIZABETH
Last Name:JOHNSON-CLARK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:KATELYN
Other - Middle Name:ELIZABETH
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 1252
Mailing Address - Street 2:
Mailing Address - City:ELLICOTTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14731-1252
Mailing Address - Country:US
Mailing Address - Phone:941-441-7804
Mailing Address - Fax:
Practice Address - Street 1:1800 MAPLE RD STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2749
Practice Address - Country:US
Practice Address - Phone:716-636-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261977208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program