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General NPI Number Information
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NPI Number | 1487047767
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Entity Type | Individual
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Provider Name | STEPHANIE LYNN CLARK ATC
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Gender | Female
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Dates
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Enumeration Date | 03/11/2015
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Last Update Date | 03/11/2015
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Provider Practice Location Address
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Address Line | 105 CREDES LNDG
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City | ELKVIEW
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State | WV
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Zip | 25071-8185
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Country | US
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Telephone | 304-965-7979
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Fax |
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Provider Business Mailing Address
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Address Line | 1 ALEXA WAY APT 4
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City | ELKVIEW
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State | WV
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Zip | 25071-9473
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Country | US
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Telephone | 304-904-5531
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 50665
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License Number State | WV
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