Healthcare Provider Details

I. General information

NPI: 1336535624
Provider Name (Legal Business Name): KOLU S. BAYSAH CLARK DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

IV. Provider business mailing address

455 TOLLGATE RD PROFESSIONAL REVENUE CYCLE AND CREDENTIALING
WARWICK RI
02886-2759
US

V. Phone/Fax

Practice location:
  • Phone: 401-737-7010
  • Fax:
Mailing address:
  • Phone: 401-273-0641
  • Fax: 401-273-2919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN00086
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2269378
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN00086
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN2269378
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN00086
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: