Provider Demographics
NPI:1063223964
Name:CLARK, ANNIQUE
Entity type:Individual
Prefix:
First Name:ANNIQUE
Middle Name:
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 1:1813 N 38TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68111-4006
Mailing Address - Country:US
Mailing Address - Phone:402-305-8419
Mailing Address - Fax:
Practice Address - Street 1:1813 N 38TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68111-4006
Practice Address - Country:US
Practice Address - Phone:402-305-8419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant