Healthcare Provider Details

I. General information

NPI: 1467369819
Provider Name (Legal Business Name): AMANDA CLARK
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 CABIN CREEK RD
DAWES WV
25054
US

IV. Provider business mailing address

PO BOX 233
DAWES WV
25054-0233
US

V. Phone/Fax

Practice location:
  • Phone: 681-552-8169
  • Fax:
Mailing address:
  • Phone: 681-552-8169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: