Healthcare Provider Details

I. General information

NPI: 1497708572
Provider Name (Legal Business Name): BENJAMIN S CLARK FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108C MCMEANS AVE
BAY MINETTE AL
36507-3130
US

IV. Provider business mailing address

108C MCMEANS AVE
BAY MINETTE AL
36507-3130
US

V. Phone/Fax

Practice location:
  • Phone: 251-445-3391
  • Fax: 251-445-3722
Mailing address:
  • Phone: 251-445-3391
  • Fax: 251-445-3722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-098021
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: