Provider Demographics
NPI:1669137543
Name:CLARK, KISHA M
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:M
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 1:2920 OAK RD APT 2106
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-8823
Mailing Address - Country:US
Mailing Address - Phone:713-913-0535
Mailing Address - Fax:281-710-0930
Practice Address - Street 1:2920 OAK RD APT 2106
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8823
Practice Address - Country:US
Practice Address - Phone:713-913-0535
Practice Address - Fax:281-710-0930
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor