Provider Demographics
NPI:1992545628
Name:CLARK, REBECCA NOELLE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:NOELLE
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 1:5317 TRENTON FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-1504
Mailing Address - Country:US
Mailing Address - Phone:513-649-5951
Mailing Address - Fax:
Practice Address - Street 1:4459 MAXWELL DR
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-4621
Practice Address - Country:US
Practice Address - Phone:513-649-5951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant