Provider Demographics
NPI:1114996931
Name:CLARK, KIMBERLY SUE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 ATKINS RD.
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:OH
Mailing Address - Zip Code:44041
Mailing Address - Country:US
Mailing Address - Phone:440-218-0392
Mailing Address - Fax:
Practice Address - Street 1:523 ATKINS RD.
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:OH
Practice Address - Zip Code:44041
Practice Address - Country:US
Practice Address - Phone:440-218-0392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN096694164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2123991Medicaid