Provider Demographics
NPI:1982471066
Name:MOOSE-CLARK, SHANA MARIE
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:MARIE
Last Name:MOOSE-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 1:3686 INGLESIDE RD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5056
Mailing Address - Country:US
Mailing Address - Phone:216-816-8129
Mailing Address - Fax:
Practice Address - Street 1:3686 INGLESIDE RD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-5056
Practice Address - Country:US
Practice Address - Phone:216-816-8129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health