Provider Demographics
NPI:1669823373
Name:CLARK, ALLYSON (OTR/L)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 PARADISE LN
Mailing Address - Street 2:
Mailing Address - City:SAXE
Mailing Address - State:VA
Mailing Address - Zip Code:23967-5529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:490 PARADISE LN
Practice Address - Street 2:
Practice Address - City:SAXE
Practice Address - State:VA
Practice Address - Zip Code:23967-5529
Practice Address - Country:US
Practice Address - Phone:434-454-0629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0119006394314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility