MEDICARE: MISS MARNISE DANNETTE CLARK LPN

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	PN-121824	OH

General Provider Information

NPI Number	:	1811011059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MARNISE DANNETTE CLARK LPN

Provider Business Mailing Address
First Line	:	4484 LONGLEAF RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-5007
Country	:	US
Telephone Number	:	216-765-1318
Fax Number	:	216-765-1318

Provider Business Practice Location Address
First Line	:	4484 LONGLEAF RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-5007
Country	:	US
Telephone Number	:	216-765-1318
Fax Number	:	216-765-1318

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

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	07/08/2007

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