Provider Demographics
NPI:1811086903
Name:CLARK, KELLY O'BRIAN (RN, MSN, FNP)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:O'BRIAN
Last Name:CLARK
Suffix:
Gender:M
Credentials:RN, MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 S EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KNOX
Mailing Address - State:IN
Mailing Address - Zip Code:46534-8226
Mailing Address - Country:US
Mailing Address - Phone:574-772-6030
Mailing Address - Fax:574-772-7494
Practice Address - Street 1:1002 S EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-8226
Practice Address - Country:US
Practice Address - Phone:574-772-6030
Practice Address - Fax:574-772-7494
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000435A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN760990DMedicare ID - Type Unspecified
INP80555Medicare UPIN