Provider Demographics
NPI:1619531936
Name:CLARK, ILEHA M
Entity Type:Individual
Prefix:MISS
First Name:ILEHA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ILEHA
Other - Middle Name:CLARK
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:152 NEW ST STE 103M
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7304
Mailing Address - Country:US
Mailing Address - Phone:478-259-1756
Mailing Address - Fax:
Practice Address - Street 1:152 NEW ST STE 103M
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7304
Practice Address - Country:US
Practice Address - Phone:478-508-7124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No372500000XNursing Service Related ProvidersChore Provider