Provider Demographics
NPI:1558924696
Name:CLEMENT, DAVIECE NICKEE (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:DAVIECE
Middle Name:NICKEE
Last Name:CLEMENT
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:0 E 4TH ST STE 14B
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-4202
Mailing Address - Country:US
Mailing Address - Phone:804-608-9453
Mailing Address - Fax:
Practice Address - Street 1:0 E 4TH ST STE 14B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-4202
Practice Address - Country:US
Practice Address - Phone:804-608-9453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12040201811744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAS4080405-5OtherVA STATE CORPORATION COMMISSION