Provider Demographics
NPI:1275848376
Name:CLARKE, KIESHA-LUE
Entity Type:Individual
Prefix:
First Name:KIESHA-LUE
Middle Name:
Last Name:CLARKE
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 1:4680 CASPIAN WAY
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-4371
Mailing Address - Country:US
Mailing Address - Phone:954-274-6464
Mailing Address - Fax:
Practice Address - Street 1:4680 CASPIAN WAY
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33314-3331
Practice Address - Country:US
Practice Address - Phone:954-274-6464
Practice Address - Fax:954-274-6464
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide