Provider Demographics
NPI:1902697667
Name:CLARK, GANIECE (PHLEBOTOMIST)
Entity type:Individual
Prefix:
First Name:GANIECE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:PHLEBOTOMIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 SW HAMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5629
Mailing Address - Country:US
Mailing Address - Phone:954-696-6980
Mailing Address - Fax:
Practice Address - Street 1:891 SW HAMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-5629
Practice Address - Country:US
Practice Address - Phone:954-696-6980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy