Healthcare Provider Details

I. General information

NPI: 1215480900
Provider Name (Legal Business Name): AMANDA CLARK CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA LYNN YEARY

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2139 AUBURN AVE
CINCINNATI OH
45219-2906
US

IV. Provider business mailing address

237 WILLIAM HOWARD TAFT RD 2ND FLOOR, CBO 2-3
CINCINNATI OH
45219-2610
US

V. Phone/Fax

Practice location:
  • Phone: 513-206-1180
  • Fax:
Mailing address:
  • Phone: 513-206-1180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNP-019707
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN302986
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: