Provider Demographics
NPI:1861238453
Name:CLARK, SHIKEMA MONIQUE
Entity type:Individual
Prefix:MS
First Name:SHIKEMA
Middle Name:MONIQUE
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 1:30 W COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-2411
Mailing Address - Country:US
Mailing Address - Phone:516-385-2323
Mailing Address - Fax:
Practice Address - Street 1:30 W COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-2411
Practice Address - Country:US
Practice Address - Phone:516-385-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist