Provider Demographics
NPI:1114651643
Name:CLARK, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
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 1:6913 EAGLES LNDG
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-1916
Mailing Address - Country:US
Mailing Address - Phone:405-887-8384
Mailing Address - Fax:
Practice Address - Street 1:2401 W I 44 SERVICE RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-8713
Practice Address - Country:US
Practice Address - Phone:405-336-1665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK82-1287880OtherPRIVATE DUTY HOME CARE