Basic Information
| Provider Information | |||||||||
| NPI: | 1609899871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | ANNE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQUARE | ||||||||
| Address2: | |||||||||
| City: | ZEPHRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137801255 | ||||||||
| FaxNumber: | 8137809773 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 VIA BELLA BLVD | ||||||||
| Address2: | STE. 204 | ||||||||
| City: | LAND O LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346395429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137513636 | ||||||||
| FaxNumber: | 8133771678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP1600042 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 300899100 | 05 | FL | MEDICAID | 500014246 | 01 | FL | RR MEDICARE | OTHER |