Provider Demographics
NPI:1487047767
Name:CLARK, STEPHANIE LYNN (ATC)
Entity type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ALEXA WAY APT 4
Mailing Address - Street 2:
Mailing Address - City:ELKVIEW
Mailing Address - State:WV
Mailing Address - Zip Code:25071-9473
Mailing Address - Country:US
Mailing Address - Phone:304-904-5531
Mailing Address - Fax:
Practice Address - Street 1:105 CREDES LNDG
Practice Address - Street 2:
Practice Address - City:ELKVIEW
Practice Address - State:WV
Practice Address - Zip Code:25071-8185
Practice Address - Country:US
Practice Address - Phone:304-965-7979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV506652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer