Provider Demographics
NPI:1487947636
Name:CLARK, NANCY LEE (OT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 PARK RD
Mailing Address - Street 2:
Mailing Address - City:ROSE HILL
Mailing Address - State:KS
Mailing Address - Zip Code:67133-9438
Mailing Address - Country:US
Mailing Address - Phone:316-640-2167
Mailing Address - Fax:
Practice Address - Street 1:849 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOWARD
Practice Address - State:KS
Practice Address - Zip Code:67349-9418
Practice Address - Country:US
Practice Address - Phone:620-374-2495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-01420174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist