Provider Demographics
NPI:1306134317
Name:CLARK, KRISTEN NICOLE (OD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 757
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-0757
Mailing Address - Country:US
Mailing Address - Phone:800-325-7706
Mailing Address - Fax:309-829-8397
Practice Address - Street 1:2435 VILLAGE GREEN PL
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7676
Practice Address - Country:US
Practice Address - Phone:800-325-7706
Practice Address - Fax:309-829-8397
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010447152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist