Provider Demographics
NPI:1073639621
Name:CLARK, ROWENA LYNETTE (COTA)
Entity type:Individual
Prefix:
First Name:ROWENA
Middle Name:LYNETTE
Last Name:CLARK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 MINCER AVE
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:KS
Mailing Address - Zip Code:67578-1208
Mailing Address - Country:US
Mailing Address - Phone:620-234-5721
Mailing Address - Fax:620-234-5721
Practice Address - Street 1:700 MONTEREY PL
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-2266
Practice Address - Country:US
Practice Address - Phone:620-664-6219
Practice Address - Fax:620-663-3133
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00071174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist