Provider Demographics
NPI:1235938200
Name:CLARK, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CLARK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17012 CORBY ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-2215
Mailing Address - Country:US
Mailing Address - Phone:801-792-2848
Mailing Address - Fax:
Practice Address - Street 1:19616 G CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-1828
Practice Address - Country:US
Practice Address - Phone:303-842-7235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator