Provider Demographics
NPI:1316238629
Name:CLARK, CHAUNDREA NICOLE (STNA)
Entity type:Individual
Prefix:
First Name:CHAUNDREA
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11200 PARKVIEW AVE
Mailing Address - Street 2:APARTMENT 4
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-5074
Mailing Address - Country:US
Mailing Address - Phone:216-231-4682
Mailing Address - Fax:
Practice Address - Street 1:11200 PARKVIEW AVE
Practice Address - Street 2:APARTMENT 4
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-5074
Practice Address - Country:US
Practice Address - Phone:216-231-4682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401021201209376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide