Provider Demographics
NPI:1679308423
Name:CLARK, HEATHER (APRN PMHNP-BC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 W LEXINGTON AVE STE C
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-1290
Mailing Address - Country:US
Mailing Address - Phone:859-385-4093
Mailing Address - Fax:859-355-5368
Practice Address - Street 1:1145 W LEXINGTON AVE STE C
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1290
Practice Address - Country:US
Practice Address - Phone:859-385-4093
Practice Address - Fax:859-355-5368
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4026229363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7101030890Medicaid