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NPI Code Detail

MEDICARE: KRISTYN LYN CLARK

MEDICARE: KRISTYN LYN CLARK
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
1363LF0000XFamily Nurse Practitioner3012305KY

General Provider Information

NPI Number : 1982193298
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRISTYN LYN CLARK
Provider Business Mailing Address
First Line : PO BOX 776351
Second Line :
City : CHICAGO
State : IL
Zip : 60677-6351
Country : US
Telephone Number : 502-588-9490
Fax Number : 502-272-5116
Provider Business Practice Location Address
First Line : 2021 HIKES LN
Second Line :
City : LOUISVILLE
State : KY
Zip : 40218-4817
Country : US
Telephone Number : 502-446-5555
Fax Number : 502-394-3673
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/02/2018
Last Update Date : 04/03/2023

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