Provider Demographics
NPI:1437210226
Name:FLACK, CLARA ELLEN (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:CLARA
Middle Name:ELLEN
Last Name:FLACK
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:MRS
Other - First Name:CLARA
Other - Middle Name:ELLEN
Other - Last Name:WEIST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:1412 HICKORY RUN DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-1517
Mailing Address - Country:US
Mailing Address - Phone:937-360-1088
Mailing Address - Fax:
Practice Address - Street 1:1412 HICKORY RUN DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-1517
Practice Address - Country:US
Practice Address - Phone:937-360-1088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN263391163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2182838Medicaid