MEDICARE: SHANE RENEE CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	194609	OH

General Provider Information

NPI Number	:	1023956257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE RENEE CLARK

Provider Business Mailing Address
First Line	:	5107 GOODYEAR DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45406-1135
Country	:	US
Telephone Number	:	937-422-6497
Fax Number	:

Provider Business Practice Location Address
First Line	:	5107 GOODYEAR DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45406-1135
Country	:	US
Telephone Number	:	937-422-6497
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2026
Last Update Date	:	03/21/2026

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Directions to “ SHANE RENEE CLARK ” Practice Location

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