Basic Information
| Provider Information | |||||||||
| NPI: | 1669144846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | APRIL | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOS | ||||||||
| OtherFirstName: | APRIL | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 932909 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441930026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308544281 | ||||||||
| FaxNumber: | 3308540829 | ||||||||
| Practice Location | |||||||||
| Address1: | 860 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | WADSWORTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442819052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303317106 | ||||||||
| FaxNumber: | 3303317556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2021 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0029716 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LG0600X | 0029716 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | 0029716 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.