MEDICARE: STACIA CLARKE

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	164W00000X	Licensed Practical Nurse	PN5175027	FL

General Provider Information

NPI Number	:	1629291331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIA CLARKE

Provider Business Mailing Address
First Line	:	1286 SWEET VIOLET CT
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33415-4519
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1286 SWEET VIOLET CT
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33415-4519
Country	:	US
Telephone Number	:	754-244-2487
Fax Number	:

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

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	07/08/2007

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Directions to “ STACIA CLARKE ” Practice Location

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