Provider Demographics
NPI:1417659095
Name:CLARK, DAWN KAY
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:KAY
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 1:122 S CRIM AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:BELINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26250-6601
Mailing Address - Country:US
Mailing Address - Phone:304-516-6702
Mailing Address - Fax:
Practice Address - Street 1:122 S CRIM AVE APT 205
Practice Address - Street 2:
Practice Address - City:BELINGTON
Practice Address - State:WV
Practice Address - Zip Code:26250-6601
Practice Address - Country:US
Practice Address - Phone:304-516-6702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker