Provider Demographics
NPI:1730430307
Name:CLARK, LONNA MARIE (LPN)
Entity type:Individual
Prefix:MS
First Name:LONNA
Middle Name:MARIE
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 1:640 HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44904-1819
Mailing Address - Country:US
Mailing Address - Phone:419-571-2545
Mailing Address - Fax:
Practice Address - Street 1:640 HOLIDAY DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44904-1819
Practice Address - Country:US
Practice Address - Phone:419-571-2545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN054675164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse