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1528614153 NPI number — KELLY ANN CLARK DPT, PT, MT

NPI Number: 1528614153
Health Care Provider/Practitioner: KELLY ANN CLARK DPT, PT, MT

Information about “1528614153” NPI (KELLY ANN CLARK DPT, PT, MT) exists in 1528614153 in HTML format HTML  |  1528614153 in plain Text format TXT  |  1528614153 in PDF (Portable Document Format) PDF  |  1528614153 in an XML format XML  formats.

NPI Number : 1528614153 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1528614153",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "CLARK",
    "FirstName": "KELLY",
    "MiddleName": "ANN",
    "NamePrefix": "DR.",
    "NameSuffix": null,
    "Credential": "DPT, PT, MT",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "2620 N WALNUT ST",
    "SecondLineMailingAddress": "SUITE 600",
    "MailingAddressCityName": "BLOOMINGTON",
    "MailingAddressStateName": "IN",
    "MailingAddressPostalCode": "47404-2008",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "812-558-0708",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "2620 N WALNUT ST",
    "SecondLinePracticeLocationAddress": "SUITE 600",
    "PracticeLocationAddressCityName": "BLOOMINGTON",
    "PracticeLocationAddressStateName": "IN",
    "PracticeLocationAddressPostalCode": "47404-2008",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "812-558-0708",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "08/09/2019",
    "LastUpdateDate": "08/09/2019",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "225700000X",
          "TaxonomyName": "Massage Therapist",
          "LicenseNumber": "MT21304740",
          "LicenseNumberStateCode": "IN",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "225100000X",
          "TaxonomyName": "Physical Therapist",
          "LicenseNumber": "05013530A",
          "LicenseNumberStateCode": "IN",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
      }
    }
  }
}
                
            

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