Provider Demographics
NPI:1366323362
Name:CLARK, SHAHEDA
Entity type:Individual
Prefix:
First Name:SHAHEDA
Middle Name:
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 1:414 HANEY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46613-2409
Mailing Address - Country:US
Mailing Address - Phone:574-210-5749
Mailing Address - Fax:
Practice Address - Street 1:414 HANEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46613-2409
Practice Address - Country:US
Practice Address - Phone:574-210-5749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN253Z00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No253Z00000XAgenciesIn Home Supportive Care