Provider Demographics
NPI:1316339294
Name:CLARK, ANGELA NICOLE (OTRL)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 ORIOLE LN
Mailing Address - Street 2:
Mailing Address - City:TELFORD
Mailing Address - State:TN
Mailing Address - Zip Code:37690-2370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 ORIOLE LN
Practice Address - Street 2:
Practice Address - City:TELFORD
Practice Address - State:TN
Practice Address - Zip Code:37690-2370
Practice Address - Country:US
Practice Address - Phone:423-416-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4328225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist