Provider Demographics
NPI:1730377326
Name:CLARK, TAMARA DELAVIGNE (MS, RN, CPNP-AC)
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:DELAVIGNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, RN, CPNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 E PARKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-1976
Mailing Address - Country:US
Mailing Address - Phone:937-497-8222
Mailing Address - Fax:
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN274268163WP0200X
OHNP-09601363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
No163WP0200XNursing Service ProvidersRegistered NursePediatrics