MEDICARE: STAJA 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	163W00000X	Registered Nurse	4704434979	MI

General Provider Information

NPI Number	:	1790612646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STAJA CLARK

Provider Business Mailing Address
First Line	:	2556 GARDENGATE PL
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43614-4791
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2556 GARDENGATE PL
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43614-4791
Country	:	US
Telephone Number	:	419-654-8398
Fax Number	:

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

Provider Enumeration Date	:	05/05/2026
Last Update Date	:	05/05/2026

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Directions to “ STAJA CLARK ” Practice Location

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