Healthcare Provider Details

I. General information

NPI: 1255290144
Provider Name (Legal Business Name): COURTNEY CLARK BSN, RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2026
Last Update Date: 01/17/2026
Certification Date: 01/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 E RICH ST
COLUMBUS OH
43215-5341
US

IV. Provider business mailing address

3640 NATALIE DR
GROVE CITY OH
43123-9462
US

V. Phone/Fax

Practice location:
  • Phone: 614-370-9141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number310561
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: