Healthcare Provider Details

I. General information

NPI: 1114201795
Provider Name (Legal Business Name): MELANIE JO CLARK MSN, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2011
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7926 PRESTON HIGHWAY SUITE 106
LOUISVILLE KY
40219-3848
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 502-964-4357
  • Fax: 502-966-5948
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3006627
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number3006627
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: