Provider Demographics
NPI:1245500784
Name:CLARK, VICTORIA LYNN (RN)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LYNN
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 1:1516 LENROOT RD
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:OH
Mailing Address - Zip Code:45106-8453
Mailing Address - Country:US
Mailing Address - Phone:513-458-8937
Mailing Address - Fax:
Practice Address - Street 1:4750 WESLEY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212-2244
Practice Address - Country:US
Practice Address - Phone:513-458-8937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN354193163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse