Venecia Bridgette Clark

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

2020092069 Issued in TN

Practice address

6450 Southcenter Blvd Ste 102
Tukwila, WA 98188-2552

Phone

(206) 721-6170

NPI assigned

Feb 6, 2019

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Cowlitz Indian Tribe

  • General Practice Physician
  • Longview, WA
  • NPI 1851328447
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1549411200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1647302400000",
    "number": "1982169728",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5455 65TH AVE S",
            "city": "TUKWLIA",
            "state": "WA",
            "postal_code": "98188"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6450 SOUTHCENTER BLVD STE 102",
            "city": "TUKWILA",
            "state": "WA",
            "postal_code": "981882552",
            "telephone_number": "206-721-6170"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3250 Fledgling Cir",
            "address_purpose": "LOCATION",
            "city": "Woodbridge",
            "state": "VA",
            "postal_code": "221931136",
            "country_code": "US",
            "telephone_number": "931-216-0922",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "CLARK",
        "first_name": "VENECIA",
        "middle_name": "BRIDGETTE",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-02-06",
        "last_updated": "2022-03-15",
        "certification_date": "2022-03-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP2300X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Primary Care",
            "state": "TN",
            "license": "24257",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "TN",
            "license": "2020092069",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Meagan Ciesluk
• Cindy L. Gilbert, Licsw
• Circle Medical Care Group PA
• Mya Clardy
• Crystal Jan Clark, CPC
• Chelsea Clemens, MA
• Loren Katherine Cline, LMHC
• Trevor Coapstick, BCBA, LBA
• Coast Imaging PLLC
• Jonette Coats, R.PH.

• All providers in Tukwila, WA
• Psychiatric/Mental Health Nurse Practitioner in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 15, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.