MEDICARE: KAROL ANN CLARK RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	28058608A	IN
2	163W00000X	Registered Nurse	28058608A	IN

General Provider Information

NPI Number	:	1326811142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAROL ANN CLARK RN

Provider Business Mailing Address
First Line	:	450 E 82ND ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-2210
Country	:	US
Telephone Number	:	317-965-0912
Fax Number	:

Provider Business Practice Location Address
First Line	:	450 E 82ND ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-2210
Country	:	US
Telephone Number	:	317-965-0912
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2023
Last Update Date	:	11/02/2023

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