Provider Demographics
NPI:1578214052
Name:NEBLETT, CLYDE M
Entity Type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:M
Last Name:NEBLETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-3628
Mailing Address - Country:US
Mailing Address - Phone:804-502-7868
Mailing Address - Fax:
Practice Address - Street 1:3007 GRANT ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23221-3628
Practice Address - Country:US
Practice Address - Phone:804-502-7868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-15
Last Update Date:2022-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA64200332172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver