Provider Demographics
NPI:1700524402
Name:CLARK, TIYA SHAVON
Entity Type:Individual
Prefix:
First Name:TIYA
Middle Name:SHAVON
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 1:1816 COOPER FOSTER PARK RD W APT 202
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3604
Mailing Address - Country:US
Mailing Address - Phone:440-538-9993
Mailing Address - Fax:
Practice Address - Street 1:1816 COOPER FOSTER PARK RD W APT 202
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3604
Practice Address - Country:US
Practice Address - Phone:440-538-9993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide