Provider Demographics
NPI:1336407444
Name:CLARK, MICHAEL ERIC (RN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERIC
Last Name:CLARK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 BANTING DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45121-1460
Mailing Address - Country:US
Mailing Address - Phone:937-378-4811
Mailing Address - Fax:937-378-4812
Practice Address - Street 1:75 BANTING DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121-1460
Practice Address - Country:US
Practice Address - Phone:937-378-4811
Practice Address - Fax:937-378-4812
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 300536163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health