Provider Demographics
NPI:1205502655
Name:CLARK, ALISHA VICTORIA
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:VICTORIA
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 1:2507 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-6209
Mailing Address - Country:US
Mailing Address - Phone:866-466-2475
Mailing Address - Fax:
Practice Address - Street 1:2507 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-6209
Practice Address - Country:US
Practice Address - Phone:866-466-2475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE20277501710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians