Provider Demographics
NPI:1225263072
Name:CLARK, ADRIENNE L (IDMT)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5154 ELLSWORTH AVE
Mailing Address - Street 2:BLDG 61690
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89191
Mailing Address - Country:US
Mailing Address - Phone:702-652-3507
Mailing Address - Fax:
Practice Address - Street 1:5154 ELLSWORTH AVE
Practice Address - Street 2:SUITE 61690
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89191
Practice Address - Country:US
Practice Address - Phone:702-652-3507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-22
Last Update Date:2009-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians