Provider Demographics
NPI:1548700065
Name:CLARKE, ANGEL LEE (LPTA)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:LEE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:ANGEL
Other - Middle Name:LEE
Other - Last Name:SALMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPTA
Mailing Address - Street 1:501 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-1137
Mailing Address - Country:US
Mailing Address - Phone:804-306-0698
Mailing Address - Fax:
Practice Address - Street 1:7015 CARNATION ST APT 214
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-5234
Practice Address - Country:US
Practice Address - Phone:919-327-9666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604246225200000X
VA0019004787225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist