NPIMap

Organization Active NPI

Carolyn Clark FNP LLC

Doing business as Tri-Lakes Family Care

  • Family Nurse Practitioner
  • Branson, MO
National Provider Identifier
1134500739
Registry record updated Jun 9, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
2013024407 Issued in MO
Legal business name
CAROLYN CLARK FNP LLC
Doing business as
Tri-Lakes Family Care
Practice address
1232 Branson Hills Pkwy Ste 106
Branson, MO 65616-4189
Phone
(417) 332-3639
Fax
(417) 332-3641
NPI assigned
Jun 9, 2015
Last updated
Jun 9, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 9, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Carolyn Clark, NP-CNPI 1679915664
Title
Owner
Phone
(417) 332-3639

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X 2013024407 MO Primary

Addresses

Primary practice location

1232 Branson Hills Pkwy Ste 106
Branson, MO 65616-4189

Mailing address

1232 Branson Hills Pkwy Ste 106
Branson, MO 65616-4189
Phone (417) 332-3639

Other identifiers 1

IdentifierTypeStateIssuer
1679915664OtherMONPI

Other names 1

  • Tri-Lakes Family Care Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150625001983 MO Part B Supplier - Clinic/Group Practice 9638480080 Receives reassigned benefits from 4 practitioners
Practice locations: Branson, MO

National Provider Directory

National Provider Directory

Locations

1232 Branson Hills Pkwy
Ste 106
Branson, MO 65616
Phone (417) 332-3636

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1433808000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1433808000000",
    "number": "1134500739",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1232 BRANSON HILLS PKWY STE 106",
            "city": "BRANSON",
            "state": "MO",
            "postal_code": "656164189",
            "telephone_number": "417-332-3639",
            "fax_number": "417-332-3641"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1232 BRANSON HILLS PKWY STE 106",
            "city": "BRANSON",
            "state": "MO",
            "postal_code": "656164189",
            "telephone_number": "417-332-3639",
            "fax_number": "417-332-3641"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CAROLYN CLARK FNP LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-06-09",
        "last_updated": "2015-06-09",
        "status": "A",
        "authorized_official_last_name": "CLARK",
        "authorized_official_first_name": "CAROLYN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "417-332-3639",
        "authorized_official_credential": "NP-C"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "MO",
            "license": "2013024407",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1679915664",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tri-Lakes Family Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Branson, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 9, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.