Provider Demographics
NPI:1760816326
Name:CLARK, STEPHANIE DIANE
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:DIANE
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 1:4613 SE 41ST ST
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-3703
Mailing Address - Country:US
Mailing Address - Phone:405-635-7856
Mailing Address - Fax:405-602-0802
Practice Address - Street 1:4613 SE 41ST ST
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-3703
Practice Address - Country:US
Practice Address - Phone:405-635-7856
Practice Address - Fax:405-602-0802
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator