Provider Demographics
NPI:1457190928
Name:CLARK, MELINDA SUE
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:SUE
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 1:202639 E CR 42
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801
Mailing Address - Country:US
Mailing Address - Phone:580-808-0143
Mailing Address - Fax:580-254-5355
Practice Address - Street 1:202639 E CR 42
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801
Practice Address - Country:US
Practice Address - Phone:580-808-0143
Practice Address - Fax:580-254-5355
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator