Healthcare Provider Details

I. General information

NPI: 1043768104
Provider Name (Legal Business Name): KATIE LYNN CLARK RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2016
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 E MAIN ST
WHITEHALL OH
43213-3593
US

IV. Provider business mailing address

4000 E MAIN ST
WHITEHALL OH
43213-3593
US

V. Phone/Fax

Practice location:
  • Phone: 614-639-6919
  • Fax:
Mailing address:
  • Phone: 614-639-6919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.403462
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0039904
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: