Provider Demographics
NPI:1053145581
Name:CLARK, KEYONDRA (BSN RN)
Entity type:Individual
Prefix:
First Name:KEYONDRA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:BSN RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CARSON DR
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-6776
Mailing Address - Country:US
Mailing Address - Phone:229-699-2020
Mailing Address - Fax:
Practice Address - Street 1:411 W 24TH AVE
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3941
Practice Address - Country:US
Practice Address - Phone:229-699-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care