Provider Demographics
NPI:1710963657
Name:CLARK, YVONNE Y (CNP)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:Y
Last Name:CLARK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 YANKEE PARK PL
Mailing Address - Street 2:STE A
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-1838
Mailing Address - Country:US
Mailing Address - Phone:937-439-4949
Mailing Address - Fax:937-439-4948
Practice Address - Street 1:1550 YANKEE PARK PL
Practice Address - Street 2:STE A
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-1838
Practice Address - Country:US
Practice Address - Phone:937-439-4949
Practice Address - Fax:937-439-4948
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA-07925-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2517342Medicaid
OHQ26638Medicare UPIN
OHCLNP16544Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #