Healthcare Provider Details

I. General information

NPI: 1457423055
Provider Name (Legal Business Name): CAROL D. CLARK ARNP, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 02/14/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13880 SHELL POINT PLAZA SUITE 110
FORT MYERS FL
33908-3504
US

IV. Provider business mailing address

13880 SHELL POINT PLAZA SUITE 110
FORT MYERS FL
33908-3504
US

V. Phone/Fax

Practice location:
  • Phone: 239-466-1111
  • Fax: 239-454-2111
Mailing address:
  • Phone: 239-454-2146
  • Fax: 239-454-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberARNP9191162
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: