Healthcare Provider Details

I. General information

NPI: 1508558610
Provider Name (Legal Business Name): KATELYNN NIKOLE CLARK MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 7TH AVE S
BIRMINGHAM AL
35233-2005
US

IV. Provider business mailing address

2215 5TH AVE S
IRONDALE AL
35210-1632
US

V. Phone/Fax

Practice location:
  • Phone: 205-934-3387
  • Fax:
Mailing address:
  • Phone: 256-399-3098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number32175
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: