Provider Demographics
NPI:1427752245
Name:CLARK, TEQUILA DIONTA
Entity type:Individual
Prefix:
First Name:TEQUILA
Middle Name:DIONTA
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 1:2460 CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-3916
Mailing Address - Country:US
Mailing Address - Phone:314-393-7395
Mailing Address - Fax:314-733-5684
Practice Address - Street 1:1169 N HIGHWAY 67 ST
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-4701
Practice Address - Country:US
Practice Address - Phone:314-733-5683
Practice Address - Fax:314-733-5684
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health