Provider Demographics
NPI:1730623141
Name:CLARK, TAMIKA (NP)
Entity type:Individual
Prefix:
First Name:TAMIKA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 VINE ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64109-1339
Mailing Address - Country:US
Mailing Address - Phone:816-405-0386
Mailing Address - Fax:510-319-8402
Practice Address - Street 1:2811 VINE ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64109-1339
Practice Address - Country:US
Practice Address - Phone:816-405-0386
Practice Address - Fax:510-319-8402
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016041521363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1730623141Medicaid
KS201153460CMedicaid