Provider Demographics
NPI:1881726271
Name:CLARK, SHANNON DENISE (CNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DENISE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:DENISE
Other - Last Name:LARGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2 EASTON OVAL STE 450
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-6035
Mailing Address - Country:US
Mailing Address - Phone:614-475-9500
Mailing Address - Fax:614-475-9821
Practice Address - Street 1:2 EASTON OVAL STE 450
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-6035
Practice Address - Country:US
Practice Address - Phone:614-475-9500
Practice Address - Fax:614-475-9821
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023853363LP0808X
OHRN-2538193747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2716887Medicaid