Provider Demographics
NPI:1821589185
Name:LEO-CLARK, SANDRA A (RN)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:A
Last Name:LEO-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 1:253 WHISTLEBERRY DR
Mailing Address - Street 2:
Mailing Address - City:MARSTONS MILLS
Mailing Address - State:MA
Mailing Address - Zip Code:02648-1447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:253 WHISTLEBERRY DR
Practice Address - Street 2:
Practice Address - City:MARSTONS MILLS
Practice Address - State:MA
Practice Address - Zip Code:02648-1447
Practice Address - Country:US
Practice Address - Phone:508-364-0690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA168434163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA163WP2201XMedicaid