MEDICARE: ERICKA CLARK FNP-C

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN11017507	FL
2	363LF0000X	Family Nurse Practitioner	AC005986	MD

General Provider Information

NPI Number	:	1558842930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICKA CLARK FNP-C

Provider Business Mailing Address
First Line	:	1600 CRAIN HWY S STE 301
Second Line	:
City	:	GLEN BURNIE
State	:	MD
Zip	:	21061-6446
Country	:	US
Telephone Number	:	410-787-8315
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 CRAIN HWY S STE 301
Second Line	:
City	:	GLEN BURNIE
State	:	MD
Zip	:	21061-6446
Country	:	US
Telephone Number	:	410-787-8315
Fax Number	:

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

Provider Enumeration Date	:	08/23/2018
Last Update Date	:	12/01/2023

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