Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | CR567 | ME |
NPI | 1043204993 |
---|---|
Provider Name | Ms. Kathleen M Clark |
First Address | Hartland, ME 04943-3710 |
Second Address | Hartland, ME 04943-3710 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
015106 | BCBS (01) | ME |