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General NPI Number Information
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NPI Number | 1023575891
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Entity Type | Individual
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Provider Name | KRISTEN CLARK MS, ATC
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Gender | Female
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Dates
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Enumeration Date | 02/27/2019
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Last Update Date | 02/27/2019
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Provider Practice Location Address
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Address Line | 537 UNION AVE
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City | GRANTS PASS
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State | OR
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Zip | 97527-5543
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Country | US
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Telephone | 541-761-0048
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 726
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City | MERLIN
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State | OR
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Zip | 97532-0726
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Country | US
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Telephone | 541-761-0048
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 1025091
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License Number State | OR
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