Provider Demographics
NPI:1891159075
Name:CLARK CAPURRO, JANELLE
Entity Type:Individual
Prefix:
First Name:JANELLE
Middle Name:
Last Name:CLARK CAPURRO
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 1:65 REGENCY WAY STE A
Mailing Address - Street 2:NONE
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-3423
Mailing Address - Country:US
Mailing Address - Phone:775-636-7767
Mailing Address - Fax:702-830-9741
Practice Address - Street 1:65 REGENCY WAY STE A
Practice Address - Street 2:NONE
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-3423
Practice Address - Country:US
Practice Address - Phone:775-636-7767
Practice Address - Fax:702-830-9741
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1780936435Medicaid