Provider Demographics
NPI:1295311322
Name:CLARK, STELLA
Entity type:Individual
Prefix:
First Name:STELLA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1094 RICE RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:26288-8517
Mailing Address - Country:US
Mailing Address - Phone:304-847-5369
Mailing Address - Fax:
Practice Address - Street 1:1094 RICE RD
Practice Address - Street 2:
Practice Address - City:WEBSTER SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:26288-8517
Practice Address - Country:US
Practice Address - Phone:304-847-5369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
WVE6581053747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172V00000XOther Service ProvidersCommunity Health Worker