Provider Demographics
NPI:1861573156
Name:CLARK, CATHERINE E (NP)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:J
Other - Last Name:EDSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1735 S PUBLIC RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-7093
Mailing Address - Country:US
Mailing Address - Phone:303-665-3036
Mailing Address - Fax:303-665-3397
Practice Address - Street 1:1701 W 72ND AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80221-2721
Practice Address - Country:US
Practice Address - Phone:303-650-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO162502363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79958061Medicaid
CO807781Medicare UPIN
CO807781Medicare Oscar/Certification
CO79958061Medicaid