Provider Demographics
NPI:1033764121
Name:CLARK, DANA (AP,DOM)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:AP,DOM
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:
Other - Last Name:MCGRADY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AP,DOM
Mailing Address - Street 1:1529 FOREST GLEN CT
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-0017
Mailing Address - Country:US
Mailing Address - Phone:321-626-7082
Mailing Address - Fax:
Practice Address - Street 1:13035 W LINEBAUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4481
Practice Address - Country:US
Practice Address - Phone:321-626-7082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1881171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist