Healthcare Provider Details

I. General information

NPI: 1366094914
Provider Name (Legal Business Name): KRYSTA ANN CLARK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2019
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 AVENUE F SE FL 1
WINTER HAVEN FL
33880-3751
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 727-315-6775
  • Fax:
Mailing address:
  • Phone: 727-315-7469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number544669
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11018536
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN11018536
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: