Provider Demographics
NPI:1942832662
Name:CLARK, ADRIAN DENISE
Entity Type:Individual
Prefix:MRS
First Name:ADRIAN
Middle Name:DENISE
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:PO BOX 3601
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-3601
Mailing Address - Country:US
Mailing Address - Phone:804-605-0388
Mailing Address - Fax:
Practice Address - Street 1:10543 S CRATER RD
Practice Address - Street 2:
Practice Address - City:SOUTH PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23805-7333
Practice Address - Country:US
Practice Address - Phone:804-431-5585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002078009164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse