Provider Demographics
NPI:1104465822
Name:CLARK, KIERRA (RCR)
Entity type:Individual
Prefix:
First Name:KIERRA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:RCR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 SUNNY AUTUMN LN
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-4532
Mailing Address - Country:US
Mailing Address - Phone:901-254-3861
Mailing Address - Fax:
Practice Address - Street 1:5115 SUNNY AUTUMN LN
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-4532
Practice Address - Country:US
Practice Address - Phone:901-254-3861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-27
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN574173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist