Healthcare Provider Details

I. General information

NPI: 1184542789
Provider Name (Legal Business Name): KAYLA MARIE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 23RD AVE S
SEATTLE WA
98144-2309
US

IV. Provider business mailing address

1609 E COLUMBIA ST APT 3
SEATTLE WA
98122-4671
US

V. Phone/Fax

Practice location:
  • Phone: 206-219-5980
  • Fax:
Mailing address:
  • Phone: 253-249-1439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: