Healthcare Provider Details

I. General information

NPI: 1407257033
Provider Name (Legal Business Name): NCLARK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 CHAIN BRIDGE RD
FAIRFAX VA
22030-4214
US

IV. Provider business mailing address

4250 CHAIN BRIDGE RD
FAIRFAX VA
22030-4214
US

V. Phone/Fax

Practice location:
  • Phone: 703-425-2229
  • Fax:
Mailing address:
  • Phone: 703-425-2229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number10--F001
License Number StateVA

VIII. Authorized Official

Name: NANCY J CLARK
Title or Position: DIRECTOR
Credential: IBCLC
Phone: 703-425-2229