Provider Demographics
NPI:1528603768
Name:ELLIOTT-CLARK, DIANALEE
Entity Type:Individual
Prefix:
First Name:DIANALEE
Middle Name:
Last Name:ELLIOTT-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 1:7411 RIDING TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-4607
Mailing Address - Country:US
Mailing Address - Phone:880-345-9415
Mailing Address - Fax:
Practice Address - Street 1:7411 RIDING TRAIL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-4607
Practice Address - Country:US
Practice Address - Phone:880-345-9415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide