Provider Demographics
NPI:1760855456
Name:CLARK, DELANNA LEIGH (APRN)
Entity type:Individual
Prefix:DR
First Name:DELANNA
Middle Name:LEIGH
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-1870
Mailing Address - Country:US
Mailing Address - Phone:859-236-2425
Mailing Address - Fax:
Practice Address - Street 1:3750 POPLAR CORNER RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-9620
Practice Address - Country:US
Practice Address - Phone:270-692-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009843363L00000X, 364SA2200X, 364SC1501X, 364SC2300X, 364SG0600X, 364SH0200X, 364SH1100X, 364SL0600X, 364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No364SC1501XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCommunity Health/Public Health
No364SC2300XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistChronic Care
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
No364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome Health
No364SH1100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHolistic
No364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100387970Medicaid