Provider Demographics
NPI:1073188090
Name:CLARK, ANTIONETTE
Entity Type:Individual
Prefix:
First Name:ANTIONETTE
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 1:1771 E FLAMINGO RD STE 220A
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-0850
Mailing Address - Country:US
Mailing Address - Phone:850-543-7279
Mailing Address - Fax:
Practice Address - Street 1:1771 E FLAMINGO RD STE 220A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-0850
Practice Address - Country:US
Practice Address - Phone:850-543-7279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty