Provider Demographics
NPI:1841010899
Name:CLARKE, NASTASIA M
Entity type:Individual
Prefix:
First Name:NASTASIA
Middle Name:M
Last Name:CLARKE
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 1:101 COCHRAN RD
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-2559
Mailing Address - Country:US
Mailing Address - Phone:234-738-8490
Mailing Address - Fax:
Practice Address - Street 1:101 COCHRAN RD
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-2559
Practice Address - Country:US
Practice Address - Phone:234-738-8490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH601176421022251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage