Provider Demographics
NPI:1972068732
Name:CLARK-SEGOVIA, KELLEY (APRN)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:CLARK-SEGOVIA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SW 20TH PL
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-7870
Mailing Address - Country:US
Mailing Address - Phone:352-840-5437
Mailing Address - Fax:352-237-1094
Practice Address - Street 1:1900 SW 20TH PL
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-7870
Practice Address - Country:US
Practice Address - Phone:352-840-5437
Practice Address - Fax:352-237-1094
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9217063363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102036400Medicaid