Healthcare Provider Details

I. General information

NPI: 1306740337
Provider Name (Legal Business Name): LATISHA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 S 5TH AVE
HINES IL
60141-3030
US

IV. Provider business mailing address

235 W VAN BUREN ST UNIT 4312
CHICAGO IL
60607-3946
US

V. Phone/Fax

Practice location:
  • Phone: 708-264-2150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number041474298
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: