MEDICARE: AMY DAWN CLEMENTZ

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	314000000X	Skilled Nursing Facility	LPN.142189.MEDS-IV	OH

General Provider Information

NPI Number	:	1932854304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY DAWN CLEMENTZ

Provider Business Mailing Address
First Line	:	9470 KUNKLER RD
Second Line	:
City	:	BLOOMDALE
State	:	OH
Zip	:	44817-9710
Country	:	US
Telephone Number	:	567-208-8007
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 STERLING DR
Second Line	:
City	:	NORTH BALTIMORE
State	:	OH
Zip	:	45872-9508
Country	:	US
Telephone Number	:	419-257-2421
Fax Number	:

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

Provider Enumeration Date	:	02/15/2022
Last Update Date	:	02/15/2022

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