Individual
KELLY CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
6100 RADIO STATION ROAD, LAPLATA, MD 20646
(301) 609-9887
(301) 609-7284
Mailing address
PO BOX 2924, LA PLATA, MD 20646-2984
(301) 609-9887
(301) 609-7284
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
589561800
—
MD
Enumeration date
10/27/2009
Last updated
10/27/2009
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