Provider Demographics
NPI:1437274982
Name:CLARK, LORI ANN
Entity Type:Individual
Prefix:MISS
First Name:LORI
Middle Name:ANN
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:HC 60 BOX 15A
Mailing Address - Street 2:RUSSELLVILLE ROAD
Mailing Address - City:NALLEN
Mailing Address - State:WV
Mailing Address - Zip Code:26680-9501
Mailing Address - Country:US
Mailing Address - Phone:304-438-6795
Mailing Address - Fax:
Practice Address - Street 1:OLD MIDLAND TRAIL-RT. 60
Practice Address - Street 2:
Practice Address - City:ANSTED
Practice Address - State:WV
Practice Address - Zip Code:25812
Practice Address - Country:US
Practice Address - Phone:304-658-5271
Practice Address - Fax:304-658-4113
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000599225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant