Provider Demographics
NPI:1538760418
Name:CLARK, CHELSEA LA' BREA (CSFA)
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:LA' BREA
Last Name:CLARK
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MCDONOUGH ST APT 416
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-2289
Mailing Address - Country:US
Mailing Address - Phone:402-738-4505
Mailing Address - Fax:
Practice Address - Street 1:7700 E PARHAM RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4301
Practice Address - Country:US
Practice Address - Phone:804-747-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA173540246ZS0410X
VA199323246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Multi-Specialty