Provider Demographics
NPI:1639443658
Name:CLARK, CRYSTAL A (CMA)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2892
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43216-2892
Mailing Address - Country:US
Mailing Address - Phone:601-480-3968
Mailing Address - Fax:
Practice Address - Street 1:331 JAMESTOWN CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-4030
Practice Address - Country:US
Practice Address - Phone:601-480-3968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No376J00000XNursing Service Related ProvidersHomemaker