MEDICARE: JAVONDA M CLARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1134754559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAVONDA M CLARK

Provider Business Mailing Address
First Line	:	5225 E CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89142-1000
Country	:	US
Telephone Number	:	702-517-1237
Fax Number	:

Provider Business Practice Location Address
First Line	:	5225 E CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89142-1000
Country	:	US
Telephone Number	:	702-517-1237
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2020
Last Update Date	:	03/05/2020

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Directions to “ JAVONDA M CLARK ” Practice Location

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