Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | CH13101 | FL |
Y | 111NR0400X | Rehabilitation Chiropractor | CH13101 | FL |
NPI | 1427350461 |
---|---|
Provider Name | Dr. Kelly Darlene Clark |
First Address | Lake Butler, FL 32054-1611 |
Second Address | Lake Butler, FL 32054-1611 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/11/2010 |
Last Update Date | 18/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
201397927 | TEXAS STATE (01) | TX |