Healthcare Provider Details

I. General information

NPI: 1184132177
Provider Name (Legal Business Name): MICHELLE CLARKE CPT , CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4532 BROWNS MILL FERRY RD
LITHONIA GA
30038-4528
US

IV. Provider business mailing address

4532 BROWNS MILL FERRY RD
LITHONIA GA
30038-4528
US

V. Phone/Fax

Practice location:
  • Phone: 404-437-3540
  • Fax: 404-437-3540
Mailing address:
  • Phone: 678-362-1552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License NumberC9P4H9A3
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCN0000001529
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: