Healthcare Provider Details

I. General information

NPI: 1932090438
Provider Name (Legal Business Name): KYIA VANCE-CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2025
Last Update Date: 07/12/2025
Certification Date: 07/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 N OAKHURST DR APT 23
AURORA IL
60504-6631
US

IV. Provider business mailing address

PO BOX 381
ELGIN IL
60121-0381
US

V. Phone/Fax

Practice location:
  • Phone: 630-776-4964
  • Fax:
Mailing address:
  • Phone: 630-776-4964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: