Provider Demographics
NPI:1285395228
Name:CLARK, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
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 1:482 CANDLESTICK CT APT H
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-9205
Mailing Address - Country:US
Mailing Address - Phone:614-900-2463
Mailing Address - Fax:
Practice Address - Street 1:199 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-1301
Practice Address - Country:US
Practice Address - Phone:614-274-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist