Provider Demographics
NPI:1255593273
Name:CLARK, THOMAS JAMES (LPN)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAMES
Last Name:CLARK
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8703 SHEAR DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-8835
Mailing Address - Country:US
Mailing Address - Phone:614-339-4062
Mailing Address - Fax:
Practice Address - Street 1:8703 SHEAR DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-8835
Practice Address - Country:US
Practice Address - Phone:614-339-4062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN113367IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse