Provider Demographics
NPI:1295308088
Name:CLIETT, RICKY ALAN
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:ALAN
Last Name:CLIETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 FRIENDSHIP CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31544-1836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 1ST ST
Practice Address - Street 2:
Practice Address - City:RHINE
Practice Address - State:GA
Practice Address - Zip Code:31077-3044
Practice Address - Country:US
Practice Address - Phone:229-385-3000
Practice Address - Fax:229-385-3004
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN274538363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily