Basic Information
| Provider Information | |||||||||
| NPI: | 1699157719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHIESS | ||||||||
| OtherFirstName: | ANNA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8402 HARCOURT RD | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462602074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178023281 | ||||||||
| FaxNumber: | 3178023972 | ||||||||
| Practice Location | |||||||||
| Address1: | 8402 HARCOURT RD | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462602074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178023281 | ||||||||
| FaxNumber: | 3178023972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2015 | ||||||||
| LastUpdateDate: | 06/25/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28223105A | IN | Y | Nursing Service Providers | Registered Nurse |
No ID Information.