Basic Information
| Provider Information | |||||||||
| NPI: | 1679001317 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Practice Location | |||||||||
| Address1: | 24143 PROFESSIONAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 470257603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124968772 | ||||||||
| FaxNumber: | 8126568084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2017 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | LL40969 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 01083310A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.