Healthcare Provider Details

I. General information

NPI: 1275456493
Provider Name (Legal Business Name): MADALYN CLARK APRN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11729 ROE AVE
LEAWOOD KS
66211-2605
US

IV. Provider business mailing address

1025 STONE CREEK DR
LAWRENCE KS
66049-4777
US

V. Phone/Fax

Practice location:
  • Phone: 785-424-0198
  • Fax:
Mailing address:
  • Phone: 785-424-0198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-85957-121
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: