Healthcare Provider Details

I. General information

NPI: 1295199941
Provider Name (Legal Business Name): STACY ANN CLARK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACY N CLARK

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 BRECKENRIDGE ST
OWENSBORO KY
42303-1089
US

IV. Provider business mailing address

8211 W STATE ROUTE 66 # A
NEWBURGH IN
47630-2534
US

V. Phone/Fax

Practice location:
  • Phone: 270-683-7553
  • Fax: 270-685-8226
Mailing address:
  • Phone: 270-663-0955
  • Fax: 270-663-0957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3010213
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71007669A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: