Provider Demographics
NPI:1184132177
Name:CLARKE, MICHELLE (CPT , CNA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:CPT , CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4532 BROWNS MILL FERRY RD
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-4528
Mailing Address - Country:US
Mailing Address - Phone:678-362-1552
Mailing Address - Fax:
Practice Address - Street 1:4532 BROWNS MILL FERRY RD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-4528
Practice Address - Country:US
Practice Address - Phone:404-437-3540
Practice Address - Fax:404-437-3540
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0000001529376K00000X
GAC9P4H9A32472E0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000Medicaid