Healthcare Provider Details

I. General information

NPI: 1558924696
Provider Name (Legal Business Name): DAVIECE NICKEE CLEMENT HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

0 E 4TH ST STE 14B
RICHMOND VA
23224-4202
US

IV. Provider business mailing address

0 E 4TH ST STE 14B
RICHMOND VA
23224-4202
US

V. Phone/Fax

Practice location:
  • Phone: 804-608-9453
  • Fax:
Mailing address:
  • Phone: 804-608-9453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number1204020181
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: