Provider Demographics
NPI:1790578052
Name:CLARK, KATHRYN ANN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 FOUNDATION FRK
Mailing Address - Street 2:
Mailing Address - City:MATEWAN
Mailing Address - State:WV
Mailing Address - Zip Code:25678-7914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:283 FOUNDATION FRK
Practice Address - Street 2:
Practice Address - City:MATEWAN
Practice Address - State:WV
Practice Address - Zip Code:25678-7914
Practice Address - Country:US
Practice Address - Phone:304-426-8018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide