Provider Demographics
NPI:1386913879
Name:CLARK, ADRIENNE RENEE (ATC/LAT)
Entity type:Individual
Prefix:MRS
First Name:ADRIENNE
Middle Name:RENEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ELWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46036-8426
Mailing Address - Country:US
Mailing Address - Phone:765-437-1117
Mailing Address - Fax:
Practice Address - Street 1:2312 S DIXON RD
Practice Address - Street 2:SUITE 250
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6401
Practice Address - Country:US
Practice Address - Phone:765-455-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001446A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer