Provider Demographics
NPI:1184872442
Name:CLARK, RENITA (LPN)
Entity type:Individual
Prefix:
First Name:RENITA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12940 FAIRHILL RD
Mailing Address - Street 2:STE 71
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44120-5525
Mailing Address - Country:US
Mailing Address - Phone:216-904-8623
Mailing Address - Fax:
Practice Address - Street 1:12940 FAIRHILL RD
Practice Address - Street 2:STE 71
Practice Address - City:SHAKER HTS
Practice Address - State:OH
Practice Address - Zip Code:44120-5525
Practice Address - Country:US
Practice Address - Phone:216-904-8623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN126160164W00000X
OH3085432164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3085432Medicaid