Provider Demographics
NPI:1811011059
Name:CLARK, MARNISE DANNETTE (LPN)
Entity Type:Individual
Prefix:MISS
First Name:MARNISE
Middle Name:DANNETTE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4484 LONGLEAF RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5007
Mailing Address - Country:US
Mailing Address - Phone:216-765-1318
Mailing Address - Fax:216-765-1318
Practice Address - Street 1:4484 LONGLEAF RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-5007
Practice Address - Country:US
Practice Address - Phone:216-765-1318
Practice Address - Fax:216-765-1318
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-121824164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse