MEDICARE: SHERRIE MARIE CLARK MEDICAL ASSISTANT

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1861621690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERRIE MARIE CLARK MEDICAL ASSISTANT

Provider Business Mailing Address
First Line	:	1223 N 50TH ST
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66102-1605
Country	:	US
Telephone Number	:	816-332-7675
Fax Number	:

Provider Business Practice Location Address
First Line	:	1223 N 50TH ST
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66102-1605
Country	:	US
Telephone Number	:	816-332-7675
Fax Number	:

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

Provider Enumeration Date	:	07/14/2009
Last Update Date	:	07/14/2009

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