Provider Demographics
NPI:1538479324
Name:CLARK, KELLY S (LPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15716 W HIGH ST
Mailing Address - Street 2:P O BOX 597
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44062-9201
Mailing Address - Country:US
Mailing Address - Phone:440-632-8071
Mailing Address - Fax:
Practice Address - Street 1:15716 W HIGH ST # 597
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:OH
Practice Address - Zip Code:44062-9201
Practice Address - Country:US
Practice Address - Phone:440-632-8071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH131431164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherAPPLYING FOR NUMBER NOW.