Individual
CAROL CLARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CNP
Contact information
Practice address
9015 E 17TH ST, INDIANAPOLIS, IN 46229-2016
(317) 898-3166
(317) 898-4219
Mailing address
9015 E 17TH ST, INDIANAPOLIS, IN 46229-2016
(317) 898-3166
(317) 898-4219
Taxonomy
Speciality
Code
Description
License number
State
363LC1500X
Community Health Nurse Practitioner
71000959A
IN
363LF0000X
Family Nurse Practitioner
Primary
71000959A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200307710
—
IN
01
—
P01016729
RR MEDICARE PTAN
IN
Enumeration date
05/17/2006
Last updated
05/02/2012
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