Healthcare Provider Details

I. General information

NPI: 1619582038
Provider Name (Legal Business Name): SHANNA KAY CLARKE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4640 W COMMERCIAL BLVD
TAMARAC FL
33319-3314
US

IV. Provider business mailing address

4640 W COMMERCIAL BLVD
TAMARAC FL
33319-3314
US

V. Phone/Fax

Practice location:
  • Phone: 954-425-9449
  • Fax:
Mailing address:
  • Phone: 754-802-0693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11002775
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: