1053417907 NPI number — MRS. KELLY L CLARK PTA

Table of content: MRS. KELLY L CLARK PTA (NPI 1053417907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053417907 NPI number — MRS. KELLY L CLARK PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
KELLY
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOOD
Provider Other First Name:
KELLY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PTA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053417907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 MUSEUM RD STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72032-4761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-329-3804
Provider Business Mailing Address Fax Number:
501-329-0718

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 MUSEUM RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72032-4761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-329-3804
Provider Business Practice Location Address Fax Number:
501-329-0718
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  2010 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2010 . This is a "PTA LICENSE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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