Provider Demographics
NPI:1821531492
Name:CLARK, MADISON RAE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:RAE
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 1:411 CENTRAL METHODIST SQ
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MO
Mailing Address - Zip Code:65248-1104
Mailing Address - Country:US
Mailing Address - Phone:816-585-5717
Mailing Address - Fax:
Practice Address - Street 1:15413 E 3RD TER S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64050-2289
Practice Address - Country:US
Practice Address - Phone:816-585-5717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer