Doctor Name: | MR. KELLY O'BRIAN CLARK |
NPI Number: | 1811086903 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | R.N., M.S.N., F.N.P. |
License Number: | 71000435A |
Business Practice Address: | 1002 S Edgewood Dr Knox, IN - 465348226 |
Business Phone Number: | 5747726030 |
Business Fax Number: | 5747727494 |
Mailing Address: | 1002 S Edgewood Dr, KNOX |
State: | IN |
Postal Code: | 465348226 |
Phone Number: | 5747726030 |
Fax Number: | 5747727494 |
NPI Enumeration Date: | 10/12/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LA2200X |
License Number: | 71000435A |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IN |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Adult Health |
Taxonomy Definition: |