=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053794578
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAYNA CLARKE RN, CNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2015
-----------------------------------------------------
Last Update Date | 07/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 831 CLEVELAND ST APT 257
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29601-4431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-207-3430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 831 CLEVELAND ST APT 257
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29601-4431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-207-3430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Registered Nurse
-----------------------------------------------------
License Number | 222891
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------