Healthcare Provider Details

I. General information

NPI: 1871414359
Provider Name (Legal Business Name): BRYAN CLARK FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 DAN PROCTOR DR STE 2100
SAINT MARYS GA
31558-3895
US

IV. Provider business mailing address

65 LIGHTHOUSE WAY
WOODBINE GA
31569-4079
US

V. Phone/Fax

Practice location:
  • Phone: 912-882-6767
  • Fax: 912-882-6411
Mailing address:
  • Phone: 912-552-7023
  • Fax: 912-882-6411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP266514
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11050461
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: