Basic Information
| Provider Information | |||||||||
| NPI: | 1124101332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707802497 | ||||||||
| FaxNumber: | 2707833750 | ||||||||
| Practice Location | |||||||||
| Address1: | 990 WILKINSON TRCE STE 100 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421033404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707814043 | ||||||||
| FaxNumber: | 2707814196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 04/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3560P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 3003560 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.