Provider Demographics
NPI:1942438213
Name:CLARK, VANIESHA SUE
Entity Type:Individual
Prefix:MRS
First Name:VANIESHA
Middle Name:SUE
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 1:3118 KIRBY AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-4951
Mailing Address - Country:US
Mailing Address - Phone:330-328-5892
Mailing Address - Fax:
Practice Address - Street 1:3118 KIRBY AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-4951
Practice Address - Country:US
Practice Address - Phone:330-328-5892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400803350908376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide