Provider Demographics
NPI:1932854304
Name:CLEMENTZ, AMY DAWN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DAWN
Last Name:CLEMENTZ
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 1:9470 KUNKLER RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMDALE
Mailing Address - State:OH
Mailing Address - Zip Code:44817-9710
Mailing Address - Country:US
Mailing Address - Phone:567-208-8007
Mailing Address - Fax:
Practice Address - Street 1:600 STERLING DR
Practice Address - Street 2:
Practice Address - City:NORTH BALTIMORE
Practice Address - State:OH
Practice Address - Zip Code:45872-9508
Practice Address - Country:US
Practice Address - Phone:419-257-2421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.142189.MEDS-IV314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility