Provider Demographics
NPI:1043855687
Name:CLARK, LATRICE
Entity Type:Individual
Prefix:
First Name:LATRICE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5226 WHETSTONE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-4324
Mailing Address - Country:US
Mailing Address - Phone:336-866-9248
Mailing Address - Fax:
Practice Address - Street 1:5226 WHETSTONE RD
Practice Address - Street 2:
Practice Address - City:N CHESTERFLD
Practice Address - State:VA
Practice Address - Zip Code:23234-4324
Practice Address - Country:US
Practice Address - Phone:336-866-9248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-202031172A00000X, 3747P1801X, 376J00000X, 376K00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No172A00000XOther Service ProvidersDriverGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty