MEDICARE: MS. KERRY CLARK APRN, AGNP-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	363LP2300X	Primary Care Nurse Practitioner	0024178999	VA
2	207R00000X	Internal Medicine Physician	RN1038780	DC
3	363LA2200X	Adult Health Nurse Practitioner	0024178999	VA
4	363LG0600X	Gerontology Nurse Practitioner	0024178999	VA

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932575743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KERRY CLARK APRN, AGNP-BC

Provider Business Mailing Address
First Line	:	224D CORNWALL ST NW STE 403
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20176-2704
Country	:	US
Telephone Number	:	703-737-6010
Fax Number	:	703-443-8643

Provider Business Practice Location Address
First Line	:	4660 KENMORE AVE STE 305&500
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22304-1313
Country	:	US
Telephone Number	:	703-751-5763
Fax Number	:	703-370-8704

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

Provider Enumeration Date	:	08/15/2015
Last Update Date	:	02/17/2026

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