Basic Information
Provider Information | |||||||||
NPI: | 1740518646 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLARK | ||||||||
FirstName: | RACHEL | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 765 N HAMILTON RD | ||||||||
Address2: | STE. 255 | ||||||||
City: | GAHANNA | ||||||||
State: | OH | ||||||||
PostalCode: | 432308703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6143379100 | ||||||||
FaxNumber: | 6143370027 | ||||||||
Practice Location | |||||||||
Address1: | 765 N HAMILTON RD | ||||||||
Address2: | STE. 255 | ||||||||
City: | GAHANNA | ||||||||
State: | OH | ||||||||
PostalCode: | 432308703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6143371779 | ||||||||
FaxNumber: | 6143370027 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2009 | ||||||||
LastUpdateDate: | 12/03/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA.1193-NP | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | COA.11193-NP | 01 | OH | CERTIFIED NURSE PRACTITIONER | OTHER | RN.355902-COA1 | 01 | OH | RN | OTHER |