Provider Demographics
NPI:1043502172
Name:CLEMONS, LANNETTE A (PA)
Entity Type:Individual
Prefix:MS
First Name:LANNETTE
Middle Name:A
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7527
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-0727
Mailing Address - Country:US
Mailing Address - Phone:419-347-4177
Mailing Address - Fax:419-347-9079
Practice Address - Street 1:24 MORRIS RD STE 2
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-1170
Practice Address - Country:US
Practice Address - Phone:419-347-4177
Practice Address - Fax:419-347-9079
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50003274RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty