Healthcare Provider Details

I. General information

NPI: 1396658860
Provider Name (Legal Business Name): KAYLA MARIE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 N MARTIN AVE
GILA BEND AZ
85337
US

IV. Provider business mailing address

1830 N HARVEY AVE
PIMA AZ
85543-9768
US

V. Phone/Fax

Practice location:
  • Phone: 928-683-2286
  • Fax:
Mailing address:
  • Phone: 928-298-0550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA-050027
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: