Provider Demographics
NPI:1669054615
Name:TRADER, CLARISSA VICTORIA
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:VICTORIA
Last Name:TRADER
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 1:3564 NAVIGATOR DR
Mailing Address - Street 2:
Mailing Address - City:GREENBACKVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23356-2508
Mailing Address - Country:US
Mailing Address - Phone:757-894-8941
Mailing Address - Fax:
Practice Address - Street 1:1532 OCEAN HWY
Practice Address - Street 2:
Practice Address - City:POCOMOKE CITY
Practice Address - State:MD
Practice Address - Zip Code:21851-3023
Practice Address - Country:US
Practice Address - Phone:443-437-7128
Practice Address - Fax:443-437-7131
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002097361164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse