Provider Demographics
NPI:1669189064
Name:CLARK, AMANDA LYNN (RN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 GOLDEN GATE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-1562
Mailing Address - Country:US
Mailing Address - Phone:513-504-4280
Mailing Address - Fax:
Practice Address - Street 1:1948 N LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2648
Practice Address - Country:US
Practice Address - Phone:866-653-4263
Practice Address - Fax:800-480-7578
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.473670163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0012309Medicaid