MEDICARE: ANITA GAYLE CLARK RN

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	163WH0200X	Home Health Registered Nurse	RN204762	OH

General Provider Information

NPI Number	:	1891836102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANITA GAYLE CLARK RN

Provider Business Mailing Address
First Line	:	4523 SARATOGA PL
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-3781
Country	:	US
Telephone Number	:	937-694-7554
Fax Number	:

Provider Business Practice Location Address
First Line	:	4523 SARATOGA PL
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-3781
Country	:	US
Telephone Number	:	937-694-7554
Fax Number	:

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

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	07/08/2007

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