Provider Demographics
NPI:1043712870
Name:CLARK, ANNIE
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
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 1:3505 WHITETAIL DR E
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44904-9227
Mailing Address - Country:US
Mailing Address - Phone:419-571-2268
Mailing Address - Fax:
Practice Address - Street 1:3505 WHITETAIL DR E
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:44904-9227
Practice Address - Country:US
Practice Address - Phone:419-571-2268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10364225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist