Provider Demographics
NPI:1558928432
Name:CLARK, NICHELLE BRITTANY (IBCLC)
Entity Type:Individual
Prefix:
First Name:NICHELLE
Middle Name:BRITTANY
Last Name:CLARK
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 HILL ST
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23324-1124
Mailing Address - Country:US
Mailing Address - Phone:240-605-1611
Mailing Address - Fax:
Practice Address - Street 1:840 JUNIPER CRES STE 110
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2628
Practice Address - Country:US
Practice Address - Phone:240-605-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-25
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty