Healthcare Provider Details

I. General information

NPI: 1043707854
Provider Name (Legal Business Name): BRIANNA YVONNE CLARK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 10/22/2023
Certification Date: 10/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S MAIDEN LN
JOPLIN MO
64801-3084
US

IV. Provider business mailing address

530 S MAIDEN LN
JOPLIN MO
64801-3084
US

V. Phone/Fax

Practice location:
  • Phone: 417-782-6200
  • Fax: 417-782-6210
Mailing address:
  • Phone: 417-782-6200
  • Fax: 417-782-6210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05-45999
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: