Provider Demographics
NPI:1710557871
Name:CLARK, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:LEETONIA
Mailing Address - State:OH
Mailing Address - Zip Code:44431-1228
Mailing Address - Country:US
Mailing Address - Phone:440-725-3316
Mailing Address - Fax:
Practice Address - Street 1:13207 RAVENNA RD
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-7032
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.372889163W00000X
OH0020839367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse