Basic Information
| Provider Information | |||||||||
| NPI: | 1730377326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | DELAVIGNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS, RN, CPNP-AC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 835 E PARKWOOD ST | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453651976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374978222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 CHILDRENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147222000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 10/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0200X | RN274268 | OH | N | Nursing Service Providers | Registered Nurse | Pediatrics | 363LP0222X | NP-09601 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics, Critical Care |
No ID Information.