Healthcare Provider Details

I. General information

NPI: 1942832662
Provider Name (Legal Business Name): MRS. ADRIAN DENISE CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10543 S CRATER RD
SOUTH PRINCE GEORGE VA
23805-7333
US

IV. Provider business mailing address

PO BOX 3601
PETERSBURG VA
23805-3601
US

V. Phone/Fax

Practice location:
  • Phone: 804-431-5585
  • Fax:
Mailing address:
  • Phone: 804-605-0388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002078009
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: