Provider Demographics
NPI:1679082754
Name:CLARKE, TARA BROOKE (APRN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:BROOKE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:BROOKE
Other - Last Name:MATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:225 NATCHEZ TRACE AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7995
Mailing Address - Country:US
Mailing Address - Phone:270-783-3573
Mailing Address - Fax:270-783-4081
Practice Address - Street 1:225 NATCHEZ TRACE AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7995
Practice Address - Country:US
Practice Address - Phone:270-783-3573
Practice Address - Fax:270-783-4081
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011723363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily