Healthcare Provider Details

I. General information

NPI: 1134500739
Provider Name (Legal Business Name): CAROLYN CLARK FNP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 BRANSON HILLS PKWY STE 106
BRANSON MO
65616-4189
US

IV. Provider business mailing address

1232 BRANSON HILLS PKWY STE 106
BRANSON MO
65616-4189
US

V. Phone/Fax

Practice location:
  • Phone: 417-332-3639
  • Fax: 417-332-3641
Mailing address:
  • Phone: 417-332-3639
  • Fax: 417-332-3641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013024407
License Number StateMO

VIII. Authorized Official

Name: CAROLYN CLARK
Title or Position: OWNER
Credential: NP-C
Phone: 417-332-3639