Provider Demographics
NPI:1013568039
Name:CLARK, SANDRA D
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441-2129
Mailing Address - Country:US
Mailing Address - Phone:785-307-8875
Mailing Address - Fax:
Practice Address - Street 1:718 W 14TH ST
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-2129
Practice Address - Country:US
Practice Address - Phone:785-307-8875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider