Provider Demographics
NPI:1548229404
Name:CLARK, KATHERINE ANN (LPN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
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 1:89 LAUNDON ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6117
Mailing Address - Country:US
Mailing Address - Phone:440-323-6385
Mailing Address - Fax:
Practice Address - Street 1:89 LAUNDON ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6117
Practice Address - Country:US
Practice Address - Phone:440-323-6385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN051977164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2615398Medicaid