Provider Demographics
NPI:1568011054
Name:CLARK, IKEIA DOMMUNIQUE
Entity Type:Individual
Prefix:MS
First Name:IKEIA
Middle Name:DOMMUNIQUE
Last Name: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 1:2817 CENTRAL AVE APT 600
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-3139
Mailing Address - Country:US
Mailing Address - Phone:216-469-9900
Mailing Address - Fax:
Practice Address - Street 1:2817 CENTRAL AVE APT 600
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-3139
Practice Address - Country:US
Practice Address - Phone:216-469-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHTR270708OtherDRIVER LICENSE