Provider Demographics
NPI:1669949137
Name:CLARK, ANGEL LA'ROSE
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:LA'ROSE
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 1:8165 PLANK RD APT 315
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70811-3926
Mailing Address - Country:US
Mailing Address - Phone:225-205-5202
Mailing Address - Fax:
Practice Address - Street 1:711 COLONIAL DR STE D
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-6549
Practice Address - Country:US
Practice Address - Phone:225-246-2162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator