Provider Demographics
NPI:1578764056
Name:CLARK, WANDA LOUISE (OTA)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LOUISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1563 HARVEST COVE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-6837
Mailing Address - Country:US
Mailing Address - Phone:904-406-9239
Mailing Address - Fax:
Practice Address - Street 1:1422 SAN MARCO BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8536
Practice Address - Country:US
Practice Address - Phone:904-306-0177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA4733224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant