Provider Demographics
NPI:1174771471
Name:CLARK, CHRISTINA SIMONE (ACNP)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:SIMONE
Last Name:CLARK
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:SIMONE
Other - Last Name:BURRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 LAKESIDE AVE E
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1158
Mailing Address - Country:US
Mailing Address - Phone:216-217-3451
Mailing Address - Fax:
Practice Address - Street 1:1001 LAKESIDE AVE E
Practice Address - Street 2:SUITE 1000
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-1158
Practice Address - Country:US
Practice Address - Phone:216-217-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-29
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP10073363LA2100X
OHRN314321364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2957715Medicaid
OH2957715Medicaid