Provider Demographics
NPI:1942052691
Name:CLARK, ABIGAIL ROSE
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:ROSE
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 1:2845 ASHCROFT DR APT 8
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-8918
Mailing Address - Country:US
Mailing Address - Phone:937-423-3969
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD FL 4
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5871
Practice Address - Country:US
Practice Address - Phone:704-381-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program