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General NPI Number Information
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NPI Number | 1104443258
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Entity Type | Individual
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Provider Name | KILMENY CLARK
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Gender | Female
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Dates
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Enumeration Date | 07/05/2020
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Last Update Date | 06/09/2025
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Provider Practice Location Address
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Address Line | 3024 E EMPIRE ST
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City | BLOOMINGTON
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State | IL
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Zip | 61704-5402
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Country | US
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Telephone | 309-556-7556
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Fax | 309-556-7551
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Provider Business Mailing Address
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Address Line | 611 W PARK ST FAPC
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City | URBANA
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State | IL
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Zip | 61801-2500
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Country | US
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Telephone |
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5318-23
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085.008097
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License Number State | IL
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