Provider Demographics
NPI:1770246514
Name:CLARK, DONTA LASHARRA
Entity Type:Individual
Prefix:
First Name:DONTA
Middle Name:LASHARRA
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 1:106 SHEMPER DR APT 3
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-4419
Mailing Address - Country:US
Mailing Address - Phone:601-329-5875
Mailing Address - Fax:
Practice Address - Street 1:106 SHEMPER DR APT 3
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-4419
Practice Address - Country:US
Practice Address - Phone:601-329-5875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide