Provider Demographics
NPI:1407238660
Name:CLARK, ANDREA
Entity Type:Individual
Prefix:MS
First Name:ANDREA
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 1:2300 SEAMAN ST
Mailing Address - Street 2:APT. 101
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43605-1952
Mailing Address - Country:US
Mailing Address - Phone:419-810-2055
Mailing Address - Fax:
Practice Address - Street 1:2300 SEAMAN ST
Practice Address - Street 2:APT. 101
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43605-1952
Practice Address - Country:US
Practice Address - Phone:419-810-2055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor