Basic Information
| Provider Information | |||||||||
| NPI: | 1568094530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | LORI | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6347 LIVIA LN | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442567765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4404540708 | ||||||||
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| Practice Location | |||||||||
| Address1: | 630 E RIVER ST | ||||||||
| Address2: | |||||||||
| City: | ELYRIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440355902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403297500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2020 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 026206 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LC0200X | APRN.CNP.026206 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
No ID Information.