Provider Demographics
NPI:1982169728
Name:CLARK, VENECIA BRIDGETTE
Entity Type:Individual
Prefix:
First Name:VENECIA
Middle Name:BRIDGETTE
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 1:5455 65TH AVE S
Mailing Address - Street 2:
Mailing Address - City:TUKWLIA
Mailing Address - State:WA
Mailing Address - Zip Code:98188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6450 SOUTHCENTER BLVD STE 102
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2552
Practice Address - Country:US
Practice Address - Phone:206-721-6170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-06
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24257363LP2300X
TN2020092069363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care