Provider Demographics
NPI:1326213679
Name:CLARK, LYNN RENEE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:RENEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 STEELHEAD ST
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038
Mailing Address - Country:US
Mailing Address - Phone:503-829-7472
Mailing Address - Fax:
Practice Address - Street 1:301 RIDINGS AVENUE
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038
Practice Address - Country:US
Practice Address - Phone:503-829-5591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility