Provider Demographics
NPI:1801898440
Name:CLARK, ALICIA H (APRN)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:H
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 559
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:KY
Mailing Address - Zip Code:42064-0559
Mailing Address - Country:US
Mailing Address - Phone:270-965-5238
Mailing Address - Fax:270-965-9015
Practice Address - Street 1:518 WEST GUM STREET
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:KY
Practice Address - Zip Code:42064-1516
Practice Address - Country:US
Practice Address - Phone:270-965-5238
Practice Address - Fax:270-965-9015
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004261363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000324690OtherANTHEM BCBS
KY78011640Medicaid
P00140734OtherRAILROAD MEDICARE
Q08660Medicare UPIN
KY1276109Medicare PIN