MEDICARE: GENEVIA NICHOLE 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	376K00000X	Nurse's Aide	402087620718	OH

General Provider Information

NPI Number	:	1982296141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENEVIA NICHOLE CLARK

Provider Business Mailing Address
First Line	:	1977 WINDMILL WAY
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45240-3341
Country	:	US
Telephone Number	:	513-226-1179
Fax Number	:

Provider Business Practice Location Address
First Line	:	1977 WINDMILL WAY
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45240-3341
Country	:	US
Telephone Number	:	513-226-1179
Fax Number	:

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

Provider Enumeration Date	:	02/09/2021
Last Update Date	:	02/09/2021

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Directions to “ GENEVIA NICHOLE CLARK ” Practice Location

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