Provider Demographics
NPI:1821672460
Name:CLARK, SIERRA
Entity Type:Individual
Prefix:
First Name:SIERRA
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 1:128 E APPLE ST STE 3800
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2902
Mailing Address - Country:US
Mailing Address - Phone:937-208-2997
Mailing Address - Fax:937-208-2752
Practice Address - Street 1:128 E APPLE ST STE 3800
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2902
Practice Address - Country:US
Practice Address - Phone:937-208-2997
Practice Address - Fax:937-208-2752
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPP-000462558207V00000X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology