Healthcare Provider Details

I. General information

NPI: 1497563936
Provider Name (Legal Business Name): BERNICE MONIQUE CLARK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2024
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60205 BODNAR BLVD
MISHAWAKA IN
46544-9342
US

IV. Provider business mailing address

1133 OBRIEN ST
SOUTH BEND IN
46628-2541
US

V. Phone/Fax

Practice location:
  • Phone: 574-325-5961
  • Fax:
Mailing address:
  • Phone: 574-217-6906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71016172A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number71016172A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: