Provider Demographics
NPI:1205461266
Name:CLARK, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
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 1:229 ELMHURST RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-1420
Mailing Address - Country:US
Mailing Address - Phone:740-637-7456
Mailing Address - Fax:
Practice Address - Street 1:229 ELMHURST RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-1420
Practice Address - Country:US
Practice Address - Phone:740-637-7456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2334183Medicaid