Provider Demographics
NPI:1114674645
Name:CLARK, ANISSA BRANT (RN)
Entity Type:Individual
Prefix:MRS
First Name:ANISSA
Middle Name:BRANT
Last Name:CLARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 ESTATES RD SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-4307
Mailing Address - Country:US
Mailing Address - Phone:540-676-4806
Mailing Address - Fax:
Practice Address - Street 1:929 ESTATES RD SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-4307
Practice Address - Country:US
Practice Address - Phone:540-676-4806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001226621163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management