Provider Demographics
NPI:1164098083
Name:CLARK, CONIE
Entity Type:Individual
Prefix:
First Name:CONIE
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 1:12864 HARVESTOR AVE
Mailing Address - Street 2:
Mailing Address - City:NEW CAMBRIA
Mailing Address - State:MO
Mailing Address - Zip Code:63558-3135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 EAST ST
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:MO
Practice Address - Zip Code:63437-1902
Practice Address - Country:US
Practice Address - Phone:660-699-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020021602225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant