MEDICARE: CHAUNDREA NICOLE CLARK STNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide	401021201209	OH

General Provider Information

NPI Number	:	1316238629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAUNDREA NICOLE CLARK STNA

Provider Business Mailing Address
First Line	:	11200 PARKVIEW AVE
Second Line	:	APARTMENT 4
City	:	CLEVELAND
State	:	OH
Zip	:	44104-5074
Country	:	US
Telephone Number	:	216-231-4682
Fax Number	:

Provider Business Practice Location Address
First Line	:	11200 PARKVIEW AVE
Second Line	:	APARTMENT 4
City	:	CLEVELAND
State	:	OH
Zip	:	44104-5074
Country	:	US
Telephone Number	:	216-231-4682
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2011
Last Update Date	:	04/21/2011

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