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General NPI Number Information
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NPI Number | 1578764056
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Entity Type | Individual
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Provider Name | WANDA LOUISE CLARK OTA
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Gender | Female
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Dates
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Enumeration Date | 05/30/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1422 SAN MARCO BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32207-8536
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Country | US
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Telephone | 904-306-0177
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Fax |
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Provider Business Mailing Address
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Address Line | 1563 HARVEST COVE DR
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City | MIDDLEBURG
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State | FL
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Zip | 32068-6837
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Country | US
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Telephone | 904-406-9239
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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 | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | OTA4733
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License Number State | FL
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