Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 3652 | NE |
NPI | 1063914109 |
---|---|
Provider Name | Michelle B Clark |
First Address | Omaha, NE 68114-4113 |
Second Address | Omaha, NE 68130-1035 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/03/2018 |
Last Update Date | 05/03/2018 |