Provider Demographics
NPI:1225620610
Name:CLARK, SHEILA LYNN
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:LYNN
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 1:141 N BURKE ST
Mailing Address - Street 2:
Mailing Address - City:PRICHARD
Mailing Address - State:WV
Mailing Address - Zip Code:25555-4011
Mailing Address - Country:US
Mailing Address - Phone:740-479-1968
Mailing Address - Fax:
Practice Address - Street 1:141 N BURKE ST
Practice Address - Street 2:
Practice Address - City:PRICHARD
Practice Address - State:WV
Practice Address - Zip Code:25555-4011
Practice Address - Country:US
Practice Address - Phone:740-479-1968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-07
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000128Medicaid