Basic Information
| Provider Information | |||||||||
| NPI: | 1265665467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 910221 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753910221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205197700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1845 W ORANGE GROVE RD BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857041144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205318967 | ||||||||
| FaxNumber: | 5207427180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2009 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP3406 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | AP3406 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | RN132004 | 01 | AZ | AZ RN LICENSE | OTHER | 455938 | 05 | AZ | MEDICAID | AP3406 | 01 | AZ | AZ NP LICENSE | OTHER |