Healthcare Provider Details

I. General information

NPI: 1609701556
Provider Name (Legal Business Name): KASHEITA CLARKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 RESERVATION WAY
AUGUSTA GA
30909-4805
US

IV. Provider business mailing address

255 RESERVATION WAY
AUGUSTA GA
30909-4805
US

V. Phone/Fax

Practice location:
  • Phone: 347-883-1592
  • Fax:
Mailing address:
  • Phone: 347-883-1592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C1101X
TaxonomyCardiovascular-Interventional Technology Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: