Provider Demographics
NPI:1528783172
Name:CLARK, SHANA (LPN)
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6550
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-6550
Mailing Address - Country:US
Mailing Address - Phone:315-782-7445
Mailing Address - Fax:315-779-1184
Practice Address - Street 1:211 JB WISE PL
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2507
Practice Address - Country:US
Practice Address - Phone:315-782-7445
Practice Address - Fax:315-779-1184
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329830164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse