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General NPI Number Information
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NPI Number | 1174912406
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Entity Type | Individual
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Provider Name | GINA CLARK APRN
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Gender | Female
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Dates
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Enumeration Date | 01/09/2015
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Last Update Date | 08/16/2019
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Provider Practice Location Address
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Address Line | 4200 GARDINER VIEW AVE
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City | LOUISVILLE
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State | KY
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Zip | 40213-1877
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Country | US
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Telephone | 502-456-0494
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Fax | 502-456-0496
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Provider Business Mailing Address
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Address Line | 3120 RUNNYMEDE RD
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City | LOUISVILLE
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State | KY
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Zip | 40222-6144
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Country | US
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Telephone | 502-657-1076
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Fax | 888-959-2460
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 3008878
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 3008878
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License Number State | KY
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Taxonomy #3
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 3008878
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License Number State | KY
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