Provider Demographics
NPI:1891836102
Name:CLARK, ANITA GAYLE (RN)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:GAYLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4523 SARATOGA PL
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-3781
Mailing Address - Country:US
Mailing Address - Phone:937-694-7554
Mailing Address - Fax:
Practice Address - Street 1:4523 SARATOGA PL
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-3781
Practice Address - Country:US
Practice Address - Phone:937-694-7554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN204762163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health