MEDICARE: CAROL D. CLARK ARNP, BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	ARNP9191162	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457423055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL D. CLARK ARNP, BC

Provider Business Mailing Address
First Line	:	13880 SHELL POINT PLAZA
Second Line	:	SUITE 110
City	:	FORT MYERS
State	:	FL
Zip	:	33908-3504
Country	:	US
Telephone Number	:	239-454-2146
Fax Number	:	239-454-2111

Provider Business Practice Location Address
First Line	:	13880 SHELL POINT PLAZA
Second Line	:	SUITE 110
City	:	FORT MYERS
State	:	FL
Zip	:	33908-3504
Country	:	US
Telephone Number	:	239-466-1111
Fax Number	:	239-454-2111

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	02/14/2022

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