Provider Demographics
NPI:1275717068
Name:CLARK, LENNON LONNIE (CPM)
Entity Type:Individual
Prefix:MS
First Name:LENNON
Middle Name:LONNIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 CLARMAR DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4826
Mailing Address - Country:US
Mailing Address - Phone:503-999-1641
Mailing Address - Fax:
Practice Address - Street 1:533 CLARMAR DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4826
Practice Address - Country:US
Practice Address - Phone:503-363-4051
Practice Address - Fax:503-339-2985
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LD-10217471176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife